No. 4641.

AUGUST 10, 1912.

An AddressON

SOME POINTS IN THE DECLINE IF THEBIRTH-RATE AND DEATH-RATE.

Delivered before the Preventive Medicine Section of theCongress of the Royal Sanitary Institute at

York on July 30th, 1912,

BY SIR SHIRLEY F. MURPHY, F.R.C.S.ENG.,VICE-PRESIDENT ROYAL SANITARY INSTITUTE ; PRESIDENT OF THE

SECTION OF SANITARY SCIENCE AND PREVENTIVE MEDICINE.

LADIES AND GENTLEMEN,-I propose to-day to submit afew observations on the decline of the death-rate and ofthe birth-rate, both of which have been conspicuous in ourtime and both of which undoubtedly require unceasinginvestigation if we are to arrive at any clear appreciation ofthe causes which have governed them. For the most partattention has been directed to the decline of the death-rate,to further which a vast administration has grown up in the

.country. To this I will refer in the first instance.

DEATH-RATE.

Let me take as example the decline in the death-rate’of the population with which I am most familiar-that ofLondon. The death-rate of London has declined in the last50 years nearly 40 per cent. To be more precise, the death-rate in 1880 was 21-7 per 1000, while in 1910 it was 13-7,giving a decline of 36’9 per cent. In England and Wales,during the same period the decline in the death-rate was.35 per cent. Moreover, if we examine the death-rates of.different localities in England, we find that this decline has’been widely shared, so that it is possible for some authoritiesto claim this decline as the result of their efforts, and of.,others to plead that local sanitary negligence cannot be.alleged against them if they can point to figures of mortality.exhibiting a like trend.How far, however, are we justified in assuming that this

- conspicuous decline of mortality is due to any intentionaleffort of man to produce this result ? 1 It is a notable factthat this decline in the death-rate has in no way been limitedto England. It has been largely shared by most of the’European populations for which the figures are conveniently:available. The annual report of the Registrar-Generalsupplies the rates of mortality, year by year, since 1880 ofDenmark, Norway, Sweden, Russia, Finland, German Empire,Prussia, Austria, Hungary, Roumania, Bulgaria, Servia,Holland, Belgium, France, Switzerland, Spain, and Italy.In these countries a marked decline in the death-rate ismanifested in all but Roumania, Bulgaria, and Servia, andperhaps Russia.

Statistics published by the Ministry of Works of France 1give for a number of European countries similar informationin quinquennial periods to 1900 or to 1905, and in respect ofsome carry this information back to earlier periods than1880. It is thus seen that in England, Scotland, Denmark,:Sweden, Finland, and some other States the decline in thedeath-rate began at an earlier period than 1880.

Turning now to the towns of which information is sup-plied by a volume published in Amsterdam,2 we find the’death-rate of 67 continental towns in Germany, Austria,Hungary, Belgium, Denmark, France, Greece, Norway, Italy,Holland, Russia, Sweden, and Switzerland, with hardly an’exception, altering in the same direction. They show amarked decline during the period subsequent to 1880, and insome the decline has not been less conspicuous than inLondon. It is difficult to believe that some factor has not’been operative on a wider or more effectual scale than could’be expected from municipal action.

Infectious Diseases.Dealing first with infectious diseases, we note that almost

2verywhere the mortality from scarlet fever has greatlydeclined. Diphtheria, too, has shown a marked declineof mortality, which has been generally manifested, though

1 Statistique Internationale du Mouvement de la Population. Paris,1907.

2 No. 33 of the Statistique Démographique des Grand Villes du Monde.Bu eau Municipal de Statistique d’Amsterdam.

Denmark suffered severely and exceptionally in the early’’ nineties." Whooping-cough mortality has declined in manycountries. Small-pox, too, since the general prevalence of1870-5 has been much less fatal. Measles mortality has insome countries somewhat declined in recent years. Generaland conspicuous decline has been manifest in the death-ratefrom typhoid fever, while the mortality from typhus, so far asstatistics indicate, has in Western Europe for a number ofyears only shown any marked incidence in Scotland and

Ireland, and in these countries has greatly declined inrecent periods. ,

There is, as we know, considerable reason for thinkingthat at any rate some of the epidemic diseases occur incycles. A striking illustration of this has been the behaviourof diphtheria in England, where, having attained epidemicproportion in the early "sixties," mortality from this diseasegradually declined until the early "seventies," from whichtime it gradually increased until it attained a maximum in theI nineties," since when it has declined to the present time.Moreover, diphtheria and scarlet fever have been found byexamination of the London statistics of notification and

mortality to present, not only seasonal prevalence, butseasonal variations in age-incidence and fatality, andchanges in age distribution manifest themselves over

periods of years as times of epidemic prevalence are

approached and passed, probably depending upon variationin the quality of infectiousness. 3 Changes of this sort areobviously due to nature, and no doubt the larger prevalencesoccurring in cycles are alike due to natural causes.Whatever man may do in individual cases in the way of

isolation and disinfection, nature practically governs thecourse of epidemic prevalence, and, as we have alreadyseen, the trend of the epidemic diseases in recent years innumerous countries has been in the direction of decrease.That the decline in the general death-rate of European

countries has been directly affected by the decline in thedeath-rate from infectious diseases cannot be denied, and toshow its proportion to the death-rate from all causes, I maysay that in England the decline of mortality from small-pox,fever, measles, whooping cough, diphtheria, and croup, in1871-5 to 1901-5 has amounted to 1 - 8 deaths in the 1000 of

population, and between these periods the deaths fromall causes declined 6 in the 1000. The decline in the death-rate from these infectious diseases is responsible, therefore,for nearly 30 per cent. of the decline in the death-rate fromall causes.

T16berculosis.

A notable decrease of mortality is due to the diminisheddeath-rate from tuberculous disease, and here again I

propose to see how far this decline is widespread in Europe.Here we have a cause of mortality responsible in England in1901-5 for probably as much mortality as, or more thanfrom, all the diseases I have mentioned, if added together.Taking deaths attributed to pulmonary tuberculosis, we finda conspicuous decline manifested in nearly all the countriespreviously specified, as well as in almost all the 67 Europeanlarge towns. The widespread nature of this decline is notless notable than the decline in the death-rate from epidemicdiseases, or from all causes.The period at which this decline set in is not the same

for all countries. Thus, limiting ourselves to the periods forwhich figures are given in that volume, the " StatistiqueInternationale " shows that, while in England 4 the death-rate markedly declined during the period from 1861-5, inScotland the decline must be reckoned from some years later.In Switzerland the death-rate from pulmonary tuberculosisincreased from 1876-80 to 1886-90, after which it declined.That of Prussia is given from 1876-80, since when it hasdeclined. The rate for Norway is interesting, because from1871-5 onwards the death-rate from pulmonary tuberculosisincreased up to 1896-1900. In Denmark the pulmonarytuberculosis death-rate was falling from 1876-80, the earliestdate given ; that of Austria from 1881-5.The statistics of the 67 large European towns giving

death-rates from 1880, almost without exception manifest amarked decline of mortality from this disease, and I havebefore me a diagram showing the facts as to Hamburg, fromwhich it appears the decline began not later than the

3 Annual Reports of the Medical Officer of Health of the County ofLondon and Transactions of the Epidemiological Society, 1899-1900 and1906-1907.4 Figures for earlier years point to decline of phthisis mortality in

the quinquennium 1844-49 compared with 1838-43 and continued to thepresent time.

352 SIR SHIRLEY F. MURPHY : DECLINE OF BIRTH-RATE & DEATH-RATE.

. forties." There is, therefore, a large cause of mortalitydeclining for a number of years, the decline beingmanifest over a wide area of Europe. There doesnot appear to be any sufficient reason for thinkingthat this decline has been due to other than naturalcauses. It began before any lessons taught by Kochcould be applied, and however well-intentioned the effortsof man may have been, if we are satisfied that nature wasresponsible for the decline in countries where it set in early,we must think of the same cause being operative in countrieswhere the decline set in late. Koch’s work has, however,led us to think of tuberculosis much as we do of diseasesof the epidemic class, and we are not able to exclude thepossibility that the type of this disease is not constant.

Apart, however, from this consideration, there is much reasonfor attaching weight to the view which has been urged byProfessor Karl Pearson, that the part undoubtedly played by

I

inherited susceptibility in the prevalence of the disease mustbe having its effect, and that the elimination of the suscep-tible in past years is largely responsible for the presentdecline. The fact that more rapid decline is taking place inurban than in rural populations lends support to this view,and the delayed decline of phthisis mortality in the Highlandsto which Dr. A. Rugg Gunn has called attention is verysuggestive in this connexion. 5We may with advantage at this point consider the effect

upon the decline in the death-rate from all causes " of thedecline in the death-rate from phthisis. We have seen thedeath-rate from "all causes" in England fall from 22 in1871-75 to 16 in 1901-5, or 6 in the 1000 of population. The

phthisis death-rate fell in this period from 2-2 to 1 2, or1 in the 1000 of population. Hence the decline in phthisisis responsible for one-sixth of the decline in the death-ratefrom all causes."

Relative hafluenee of Various Factors zcpoot the IJeath-1,atefront "All Causes."

Of diseases causing considerable mortality, only in theinstance of cancer do we find notable increase of the

figures in the two periods, amounting to 0-4 in the 1000of population, and this increase is more than compensatedfor by the decrease in the mortality from the numerousmaladies, each of which does not cause large mortality,but the decline in which in the aggregate is sufficientto account for half the decline in the total death-rate of 6in the 1000 of population, diseases against which no

preventive measures have been specially directed.Stated generally, I think we may say that nearly two-

sixths of the decline in the total death-rate has been due todecreased mortality in epidemic diseases, the trend of whichis governed, in the main, by the natural behaviour of thesediseases ; that one-sixth of the decline in the total death-rate has been due to decreased mortality from phthisis,which, in various parts of Europe, was manifested before anyof the prevailing views of prevention could have been

applied, and which has probably not been materially dis-turbed in one or other direction since by any of the measureswhich have been adopted in recent years ; and that theremaining three-sixths of the decline of the total death-ratehas been shared among other causes of mortality, for whichparticular methods of prevention, as applied to populations,have hardly been discussed.

Age-incidence.A point which has been frequently noted in the behaviour

of death-rates in successive periods in the English popula-tion is the fact that the death-rates have declined most atthe younger ages, and that there has been actual increase atthe older ages. It has been suggested by the late Dr. Oglethat this increase may be due to survival in youth of com-paratively unhealthy persons, who subsequently lived longenough to increase the mortality of the population at theolder ages..The Registrar-General, however, in his annual report for

the year 1909, in discussing this subject, refers to a state-ment in the Census Report for 1901, which is to the effectthat from 30 to 60 years ago the ages of old people wereprobably overstated more than in later years, both in theCensus returns and in the death registers, with the effect(which is explained) of lowering the death-rates at the older

5 Brit. Med. Jour., Dec. 31st, 1910.

the older ages in more recent times. These higher rates atthe older ages are apparently disappearing, with the resultthat it may be said that almost all ages are experiencing-progressive decline in the rates of mortality. It would

appear, therefore, that some altered condition or conditionsaffecting the population has been responsible for the notabledecline in the mortality which we are discussing. It is,however, the special decline at the younger ages which mostdeserves attention. This decline at the younger ages is.manifest in the death-rates from different causes, and I mayrefer to the following observations of the Registrar-Generalin his annual report for the year 1909, in which he calledattention to the different periods in which special declinewas manifested in the population at the several ages. Hewrites :-

It is interesting to note that the mortality of children under fiveyears of age, which during the nineteenth century had declined less.than that of any other age-groups of children or young adults, and inthe last decade of the century showed an actual increase in both sexes,has during the present century declined more than that of any othergroup. While the present is the era of greatest decline in the

mortality of the youngest group of children, that of their immediateelders (5 to 15) declined most so far back as the "seventies" of lastcentury, while for adolescents and young adults up to the age of 25 the’"eighties were the period of greatest decline. All the above state-ments apply to both sexes, a fact which evidences the strikinguniformity of mortality in the two sexes....... From 30 to 55 the-greatest improvement has occurred, as in the case of the youngestchildren, during the decade now closing. The question suggests itselfwhether any relationship exists between these spurts in the amount ofimprovement shown by the various age-groups of the two sexes,occurring as they do simultaneouslyfor each sex, but atwidelydifferentperiods in different age-groups, and changes in the environment havinga selective influence upon different ages, but a uniform influence on thetwo sexes.

We must here observe that the population, aged 5 to 15,in the "seventies" were adolescents and young adults up to,the age of 25 in the" eighties "-that is, the next decennium-and that the population at the age 35 to 55 in the decenniumjust closing when the Registrar-General wrote (1901-1910)consisted largely of the same persons. Hence, we may saythat this population, which in successive decennia showedsuch improved death-rates, were either born an especiallyhealthy group of persons or were subject to especiallyhealthy conditions. The conditions, however, to which theywere subject were the same as those to which persons atother ages were subject. The decennium 1871-80 wascharacterised by greater decline of the death-rate at allages " than in any decennium between 1841-50 and 1881-1900. It was, moreover, a period of greatly improvedprosperity. May we, therefore, in seeking a selectiveinfluence upon age-periods of the condition or conditionswhich in 1871-80 led to marked reduction of the death-rateat "all ages," possibly find it in the age at which this

particular population was in that period? 2 We may wellthink it might have its maximum effect upon those at thegrowing age of life, and, if so, that the improved death-rates which that population experienced later in life wasattributable in some degree to the benefit conferred on it atthat age.The view that improvement in environment may thus

affect the population at the several ages in different degree,would afford explanation of the special decline at the

younger ages, and would support the hypothesis that we arehere concerned with environment as an important factor inthe decline in the death-rate. Of the causes which may be

operative in this direction, improved nutrition naturallysuggests itself as a likely influence. The recent decline inthe death-rate at ages 0-5, to which the Registrar-Generaldirects attention, appears to afford indication which is infavour of this view, for duiing this period the necessity forthe better feeding of infants and of young children has beenunceasingly urged upon the public.

It does not appear unlikely that two causes have beenoperative in the direction of a low death-rate. In the caseof such a disease as tuberculosis, the liability to which isinherited, susceptible persons would gradually be eliminatedfrom the population. In the case of various diseasesimproved environment, especially improved nutrition, maybe expected to increase resistance, and may have a maximumeffect at the younger ages. Assuming both factors to beoperative, the population of the present time should be in adifferent condition as regards susceptibility to disease thanin former years.

How the IJeath-rates are Affected by Social Conditions.

In reports presented to the London County Council I

353SIR SHIRLEY F. MURPHY : DECLINE OF BIRTH-RATE & DEATH-RATE.

nave discussed this subject. London has been divided into

groups of districts for the purpose of comparison. In

attempting to estimate the social condition of these popula-tions for a number of years after the 1901 census, I took asa standard the proportions of the total population livingmore than two in a room in tenements of not more than fiverooms. More recently, owing to the consideration that

.changes in the areas may have occurred since 1901, I havetaken as standards the proportion of children of school ageattending elementary education schools. The death-rateshave been found to decrease as we proceed from the

populations in the lower to those in the higher social-condition, may mention that mortality from pulmonarytuberculosis is conspicuous in this respect, and that

.mortality from cancer behaves independently of socialcondition when due correction is made for differences in the

age and sex constitution of the several populations. Cancer.is, however, exceptional so far as I have examined thefigures.It is evidently desirable that we should know whether the

decrease in the death-rates is progressing more rapidly in thehigher or the lower social grades of the population. I havefigures for each of our social grades in the periods1902-05 and 1906-09, and find that when comparison ismade between the three grades the amount of decline isless in the more favoured groups, and greater in the lessfavoured groups, as the following table shows :—

TABLE I.

I put these results forward, however, tentatively, for inthe last decennium considerable changes have taken place inthe constitution of the population of some of the metropolitan’boroughs.

There has, in fact, been a tendency for the workingclasses especially to migrate from London, and at the presenttime we are not in possession of information as to the sexand age distribution of the several populations at the timethe Census (1911) was taken. If later the teaching of the’figures is found to be accurate, we could reconcile thisbehaviour of the rates with the hypothesis that the decline ofthe death-rate in the total population has been affected byimproved environment. We may think of the most favoured

groups as having earlier derived most benefit from improvedconditions, and therefore experiencing between these twoperiods less change in this respect than the less favouredgroups. In consideration of this question it would be neces-sary to know how much of this decline may be of a temporarynature, as it would be if attributable to variations in preva-lence of infectious disease or of disease depending onclimatic conditions.

Improved Environwent and Natural Causes.There is, indeed, no more complex problem than that of

learning the proportion in which have been operative thevarious factors concerned in the reduction of the death-rate.There is much reason for thinking that improved environ-ment has had effect in this direction, and I do not fail toattach importance to the efforts which have been made byhealth authorities to limit or remove opportunities for infec-tion, and for increasing resistance to disease by improvingthe conditions of living, nor indeed to the effect of improvedmethods of treatment of disease ; but I wish at the presentmoment to emphasise the large part which nature has playedin the reduction of the death-rate.

BIRTH-RATE.With decline of the death-rate has occurred decline in the

birth-rate, and this decline, as in the case of the death-rate,"has been manifest over Europe. Attention has beenincreasingly directed to the question whether this declinehas been the result of intentional restriction. In the case ofhereduction of the death-rate it has been the fashion to&67

think of this as due to the intentional effort of man ; and soin the case of the decline of the birth-rate the same thoughtobtains. A diagram in the Stcctistic2c.e Internationale, how-ever, shows that increases have occurred in the past, some ofthem of considerable magnitude. The birth-rate of Swedenin 1801-10 was 31 per 1000, and in 1821-30 it was about 34 - 6 ;the birth-rate of Bavaria in 1851-60 was a little over 33 per1000, in 1871-80 it was a little over 40 ; that of Hollandin 1851-60 was a trifle over 33, in 1871-80 it was a littleover 36 ; in Saxony the birth-rate rose from 38 in 1831-40to nearly 43 in 1871-80; that of England from a littlebelow 33 in 1841-50 to a little over 35 in 1871-80.If we are to credit the birth-rate with increasing in these pro.portions as the result of natural causes, can we doubt thatnature may cause a like reduction, and is there any reasonfor assuming that a decrease may not also occur naturallyconsiderably below the rate upon that upon which theincrease took place ?

Social Conditio2is and the Birtlt-ratc.As in the matter of death-rate, it is also desirable that

we should know whether the birth-rate varies with socialcondition, and whether the decline in the birth-rate isgreater in one or another of our social groups in the Londonpopulation. I have, therefore, compared the birth-rate inour three groups in the periods 1902-05 and 1906-09, withthe result that the birth-rate follows the death-rate, and asin the death-rate the least decline is found in the mostfavoured group, the greatest decline in the least favoured

group, and a decline between the two in the intermediate

group. (See Table II.) I again wish to say that I putTABLE II.

forward these figures tentatively, for during the decenniumthere has been an increase in the extent of application ofthe system adopted in Somerset House of distributing birthsoccurring in public institutions to the districts in which themothers have previously resided, and it is possible that thishas somewhat modified the figures. As a matter of fact, ifregistered births be dealt with-i.e., births which have notbeen distributed-I find Group II. showing somewhat moredecline than Group III. There is, however, always excessof decline in Group III. over the decline in Group I. Wemust leave the future to determine whether this differencein the behaviour of the birth-rates in the groups is constant.Of course, for the precise statement of this question, it isdesirable to take into consideration the behaviour of marriage-rates, and to know whether the age of marriage is beingpostponed at different rates in the three groups. I have nothad the opportunity of studying this question.

Differences in Proportion of Sexes.I may now refer to another question which may be thought

to have bearing upon the reduction of the birth-rate. Theannual report of the Registrar-General contains figuresshowing the proportion of males and females born in

England in successive decennia since 1841-50. (SeeTable 111.). These figures show that the proportion of boys

TABLE III.

born to 1000 girls was in that decennium 1049, but pro-gressively declined until in 1891-1900 the proportion wa.s

354 SIR SHIRLEY F. MURPHY : DECLINE OF BIRTH-RATE & DEATH-]A’I’E.

1036. In the period 1901-09 it has risen to 1037, the same Ias in 1881-90.Various hypotheses have been suggested by way of

explanation of differences in the proportion of the two sexeswhich are born. One of them is that differences in registra-tion have affected this proportion. In the Stat’istÙj1le -Titter-nationale it has been pointed out that the proportion ofboys born in England is less than in Scotland, and it issuggested that inasmuch as registration of births isauthorised for a longer period after birth in England thanin Scotland, in England there is a longer interval duringwhich deaths may take place ; and that as the mortality ofboys in early life is greater than that of girls, the births ofboys dying would escape registration more largely thanthose of girls. If we accept this hypothesis, we shouldexpect to find that more complete registration as theresult of improved education and civilisation wouldhave had the effect of increasing the proportion ofmale registered births in England in successive decennia,whereas, as we have seen, it was decreasing until thelast decennium. I have compared the proportion of boys andgirls born in our three groups of London districts in 1905-07,classified on the basis of social condition, the proportions ofpopulation scheduled for attendance at elementary schoolsbeing taken as a standard of social condition. The result isthat in every 1000 girls born 1049 boys are born in the mostfavoured group, 1035 in the next group, and 1031 in the leastfavoured group. Comparison of the groups on the basis oithe births of 1901-05 and 1906-10 gives similar results.

In an interesting paper on this subject by Mr. R. C.Punnett in the Proceedings of the Cambridge PhilosophicalSociety he gives account of a like examination of the Londorpopulation, taking as his standard of social condition that o:Mr. Rowntree, of York-viz., the proportions of familie:

keeping servants. His figures give the same indications a:mine-viz., that the more prosperous populations tend t<have the greater proportion of boys. He discusses thiquestion in much detail, and shows that the earlier childre]of a marriage have a greater tendency to be boys than girlsand that in populations where families are limited this woulhave the effect of increasing the proportion of boys born. Iwe apply this observation to our three grades of population imight seem to afford explanation of the different proportioof boys born in them.There is, moreover, another point Punnett discusses, which

is of interest in its bearing upon this subject. Young mothersbetween the ages of 19 and 23 years were found to produce alarger proportion of females than older mothers, and hence,as the more improvident classes marry earlier than the moreprovident, this might also seem to afford some explanationof the difference between the proportion of male and femalebirths in the three classes of the population. The age at

marriage, however, in the population as a whole is somewhatlater than formerly, and the effect of this should be in thedirection of increase of the proportion of males born.

Nevertheless, as we have seen, in England the proportionof boys was decreasing until the last decennium. Is thereanother factor which obscures, in the total population, theeffect upon the proportion of males and females born ofsmaller families ? ‘!

Effects of Nut?’ition on Proportion of Sexes.In this connexion I may refer to observations concerning

the effect of nutrition on the proportions of the sexes. Pro-fessors Geddes and Thomson, in their work on ’’ TheEvolution of Sex," state that botanical evidence, thoughby no means strong, corroborates the general result thatgood nourishment produces a preponderance of females."There is also a good deal of evidence derived from the insectworld, that insufficiency of food leads to the birth of males.I am told that agriculturists believe that good pasturageleads to the birth of females ; and there is the experimentof Girou, cited by Geddes and Thomson, who fed two equal Inumbers of ewes, the one well, the other poorly, with theresult that the former produced marked excess of femalesover the latter. It needs, however, to be mentioned thatthe well fed were served by two young rams, while theothers were served by two mature rams. This, though intro-ducing another factor in the experiment, does not, as Geddesand Thomson say, deprive it of value.

There are, therefore, two possible factors to be considered :(a) the reduction in size of families tending to increase theproportion of males, and (b) improved nutrition tending to

increase the proportion of females. Both may_have beenoperative in recent years.

Statistics (If Otlieq’ C01l?1t?’ies.We may turn to the statistics of other countries for assist-

ance. In some we find less constancy in the behaviour ofthe figures than in England, but in some there is evidencethat, as in England, the proportion of male births has beendecreasing, while, on the other hand, in some others theindications are that the proportion of males has beenincreasing. It is difficult to believe that in France, wherethe proportion of females has increased, the effect upon sexof the declining birth-rate, which has been so widelyattributed to limitation of families, should be masked bythe counter effects of improved nutrition, or that in

Sweden, where the proportion of males has increased, theeffect of improved nutrition should be masked by the effectof limitation of families. I find it much more easy tobelieve that these proportions in the population as a wholeare not governed by either factor.

Ca1lses of -Decliqzing Birt7e-rcte.?’ Are we, then, to attach importance to restriction of births-as an explanation of the difference of the sex proportions inour three social groups? 7 I have in this matter compared

: the three groups of districts in 1901-05 and 1906-10, and’ find that with an increasing proportion of boys born in the; total population, the most favoured gioup has experienced,- in the last period, a greater increase of boys born than in

the less favoured groups. (See Table IV.) These figures,for the reasons I have already given, must be looked upon as

ll

TABLE IV.

tentative ; but if they are to be trusted they may bethought to suggest that limitation of families is increasing atgreater rate in the well-to-do than in the poor populations.This, however, is inconsistent with the apparent greaterdecline of the birth-rate in the poor population, assuming, ofcourse, that other conditions are equal. I am hesitating,therefore, at the present time to accept the greater proportionof boys born to the well-to-do population as evidence of thelimitation of the size of families in this population.

I am not proposing to contend that intentional restrictionof births has not had its effect upon the birth-rate, but itdoes not appear to me that there is any more reason for

ignoring the likelihood that nature has been largely con-

cerned in the reduction of births, than for ignoring theeffects of nature in reducing the death-rate. The decline inboth has points of resemblance. Both have been widelymanifest over Europe, both have in the main declined in theperiod of 1871-80 and subsequently, and indeed both appearto be behaving in like manner when we compare thatbehaviour in our three groups of London districts.

INFLUENCE OF HEREDITY ON BIRTH AND DEATH RATES,Consideration of death- and birth-rates in populations of

different social circumstances leads us to inquire upon whatvariations in the death-rate and birth-rate may depend.When we classify our population on the basis of the pro-portion of families keeping servants, or living in over-

crowded tenements, or sending children to elementaryschools, and find differential death-rates and birth-rates,we are not merely comparing the results of environment.These variations are in the main due to the unceasing sortingof the population, which is determined in large degree bynature, and as the result we have populations differing inpower of resistance to disease and probably also in pro-creative ability. _

Professor Karl Pearson has taught us that fertility isinherited in man. Are we to learn in the future that

morbidity is hereditary in a much wider sense than is sus-pected at present ? 7 If heredity were a large factor in our

355] MAJOR ROGERS, I.M.S.: LEUCOCYTE COUNTS IN CIRRHOSIS OF LIVER.

differential birth-rates and death-rates, we might find

relationship between fertility and tendency to disease, andthus part explanation, at any rate, of the decline of the tworates. I think that some effort should be made to study thesubject in this relation, if for no other other reason than’that of the behaviour of the death-rate and birth-rate towhich I have referred. G

THE DIAGNOSTIC AND PROGNOSTICVALUE OF LEUCOCYTE COUNTS IN

CIRRHOSIS OF THE LIVER.

BY LEONARD ROGERS, M.D. LOND., F.R.C.P. LOND.,F.R.C.S.ENG.,

MAJOR, INDIAN MEDICAL SERVICE ; PROFESSOR OF PATHOLOGY,CALCUTTA MEDICAL COLLEGE.

IN a paper published in 1911 I dealt at length with the,subject of the prevalence and varieties of cirrhosis of theliver in Calcutta, and analysed the post-mortem data of 333.cases occurring in the Medical College Hospital during the,previous 37 years. The main conclusions arrived at were the

following :-1. Cirrhosis of the liver is met with seven times as frequently in the

’Calcutta, post-mortem examinations as in those of Berlin.2. This great excess cannot be explained on the alcoholic theory of

.origin, for the disease is quite common in strict Mahamedans, whonever take alcohol, and many of the Hindu patients had not indulgedin it, while very few of them had drunk to excess.

3. One-fifth of the cases were secondary to kala-azar, being partly of,the special intralobutarform described by me, but also commonly of the-ordinary multilobular type or both varieties combined.

4. There was no evidence that malaria ever produced a clinically.evident cirrhosis, which is in accordance with Professor Osler’sexperience in Baltimore.

5. Hanot’s biliary cirrhosis is rare in Calcutta, but a somewhat similar.and very fatal form, with great enlargement of the liver, is met with in;infants.

6. Dysenteric lesions were found in 48 per cent. of ordinary cirrhosisand in 42’6 per cent. of kala-azar cases. In over three-fourths of eachform the lesions were old and probably antecedent to the cirrhosis;,thus affording strong evidence of a causal relationship. The dysenterywas usually of the amoebic type. Gastric or duodenal ulcers were alsomet with several times.

7. Chronic inflammatory changes in the gastro-intestinal tract due to,toxic absorption or bacterial infection through ulcers in the gastro-intestinal canal are. therefore, the main cause of hobnail liver, and thefrequency of chronic dysentery accounts for the great excess of cirrhosis;in Calcutta.

8. Leucocytosis is common in ordinary cirrhosis of the liver, a highdegree being of immediate very bad prognostic significance. On theother hand, a marked leucopenia is diagnostic of the disease being-secondary to kala-azar

The conclusions of the last paragraph appeared to me,to be of some practical value, as now that operative measuresare frequently undertaken in the treatment of cirrhosis ofthe liver, it is obviously a matter of great importance, if by.means of a blood count it should be possible to exclude caseswhich are likely to prove fatal at an early date, and to con-fine the surgical procedures to those in which there is a fair- chance of permanent benefit resulting. I have thereforecontinued my observations on the blood changes in cirrhosisof the liver, and as the results confirm, and in some respectsegtend, the above conclusion, I propose to deal more fullywith the subject in the present communication.For convenience of reference the cases have all been

tabulated and classified in the following way. In the first

part of Table I. are shown those cases with an actualleucocytosis, and in the second part those in which a relative’increase in the leucocytes was found. By the latter term ismeant the presence of a larger proportion than one whitecorpuscle to 500 red, together with a decrease in the totalnumber of red corpuscles below the normal, so that the white.corpuscles would be equivalent to over 10, 000 per c.mm. if thered were up to the normal standard of 5,000,000. For

example, in Case 10 there were only 8250 white corpusclesper c.mm., but the red were reduced to 3,420,000, so that theproportion of white to red was 1 to 402. There is thus no-actual leucocytosis, yet among the normal number of 5, 000, 000red corpuscles there would be 13,250 leucocytes, a relative’leucocytosis being thus present. In Cases 10 to 15 in Table I.the estimated degree of relative leucocytosis is given in

6 Dr. Lloyd Jones’s observations on the fertility of persons havingchlorotic conditions of the blood are of interest in this connexion.

1 Indian Medical Gazette, February, 1911.

brackets above the actual count. I have previously shown thatin amoebic liver abscess patients presenting some degree of

TABLE L-C6r-rltosis of the Live?’ 1vith Aat1tal or RelativeE67teocytosis.

Cases showing only a Relative Leu;ocytosis.

In second column (" Race") H = Hindu ; M = Mahamedan.

TABLE 1I.-Ci’/’1’lwsis of the Liver,7vitA Normal ordiminished Leaccoctes.

ansemia such a relative leucocytosis may be of greatdiagnostic value in the absence of an actual leucocytosis.

Similarly in the present series of cirrhosis cases it appearsthat a relative increase of the white corpuscles is of greatimmediate prognostic value. Thus, in Table I. 5 of the 9