1090 Annotations. "Ne quid nimis." POPULATION. THE population of England about A.D. 1000 was something like 1 t millions ; it slowly grew to nearly 9 millions in 1801, and then jumped up till it reached 38 millions in 1921. A hundred years ago Great Britain had twice the population of Ireland ; now it has ten times as many people. Which, Mr. A. M. Carr-Saunders says in a recently published volume,’ is I a thing the like of which has, as far as is known, never happened before and will, as far as may be guessed, never happen again. The theoretically possible multiplication of mankind is infinitely great compared with the available area of land and its utmost imaginable fertility. Birth restric- tion, Mr. Carr-Saunders holds, is a necessity, and the customs of primitive peoples show that it has always been practised ; the modern mind differs from the ancient only in asking for reasons instead of being content with religious or customary sanctions. The author is a classical Malthusian, and his argument centres round the proposition that the best number of people is that which gets the largest return out of collective human work and so achieves the highest general standard of material and spiritual life. Nomadic life fills the world with n persons per square mile, agriculture with 2 n or 10 n, according to its development, industrial concentration with 100 n or 1000 n. Whether any part of the world is over- populated or not depends therefore on the control which man can exert over his environment. That this will increase may be presumed ; it appears likely that the population of this country is reaching, or has already reached, a table condition ; there is no need for alarm, but a great necessity that the situation should be studied and understood. Such is, briefly, the main thesis of a most excellent little book. The author states the questions and argues them very clearly and gives us one of the best half- crown’s worth we have ever seen. Population, birth control, urbanisation are matters in which a great variety of people take, and ought to take, an interest ; they are of national and international significance, and if such a book as this were widely read we should do away with some of the nonsense that is talked and printed about them. The book is short and in places necessarily dogmatic; it gives, however, an admirable survey which will incite the reader to go further and tudy some of the works given in the bibliography at the end, in which, curiously enough, there is no mention of the author’s larger book " The Population Problem," published by the Clarendon Press in 1922. On one point only would we offer a suggestion. Mr. Carr-Saunders points out that nations desire to be big because they so add to their prestige, because they like as many people as possible to be of the same ideals and prejudices as themselves, and because they can more easily wave the big stick. He entirely omits the point which appeals strongly to the biologist, and especially the biometrician-that large populations are more likely than small ones to contain those exceptional variants on whom the progress and guidance of the world so much depend. SIGNIFICANCE OF MANY TUBERCLE BACILLI IN THE SPUTUM. IT is generally assumed that the number of tubercle ’I bacilli in the sputum is directly proportional to the I severity of the disease. Another common belief is I that the appearance of these bacilli varies with the I severity of the disease, short and homogeneous I 1 Population. By A. M. Carr-Saunders. London: Oxford University Press. 1925. Pp. 111. 2s. 6d. bacilli being supposed to be indicative of severe disease, whereas granular and moniliform bacilli are supposed to be coughed up by patients whose disease is comparatively slight. To provide a statistical verification of these views, Dr. T. Stefani and Dr. J. Stefani,l of Montana, have compared the clinical with the bacteriological findings at their sanatorium in the period 1898-1923. Of the 1430 patients treated, only 781, or 55 per cent., were sputum- positive. There were 303 patients in whose sputum tubercle bacilli could not be found, and 346 who did not provide sputum for examination. In 70 per cent. of the 781 sputum-positive cases, the views referred to in the opening sentences of this annotation were confirmed. Cases in which the disease was slight were marked by a paucity of tubercle bacilli in the sputum, cases in which the disease was severe were marked by the great number of bacilli, and according as the patients became better or worse, the number of the bacilli in the sputum became less or greater. In 8 per cent. these correlations were reversed, and in the remaining 22 per cent. the dwindling or augmentation of the numbers of bacilli in the sputum bore no uniform relationship to the clinical course of the case. A comparison of the appearance of the bacilli with the course of the disease showed that in 60 per cent. of all the sputum-positive cases the orthodox teaching held good. When the disease was slight, most of the bacilli were granular, when it was severe, they were short and homogeneous, when the patient was getting better, granular bacilli replaced the homogeneous bacilli, and when the patient became worse homogeneous bacilli again appeared. In 18 per cent. these correlations were reversed, and in the remaining 22 per cent. no uniform parallel could be drawn. By combining the two factors-both the number and the appearance of the bacilli in the sputum-the authors of this interesting paper show that in as great a proportion as 80 per cent. a clue is given by the microscopic examination to the prognosis. Their painstaking research is confirmatory of views held for a long time. It is so much less exciting to confirm than to subvert old teachings that the authors are to be congratulated on having conducted investigations without that incentive to work which some of us find in the prospect of proving another in the wrong. INSULIN AND INFECTION. THE article in our present issue by Dr. R. Carrasco- Formiguera, of Barcelona, on the amount of insulin required in the treatment of the surgical complications of diabetes and Dr. G. Graham’s article on the relation of infection to diabetic coma in the current number of the Quarterly <Tournal of Medicine, both draw attention to the relation of sepsis to diabetes and of the necessity of giving an adequate amount of insulin. Dr. Carrasco-Formiguera points out that there is an impression abroad, for which he regards Dr. E. P. Joslin of Boston as partly responsible, that insulin is of little value in the presence of sepsis. He thinks that this is solely dm to the use of an insufficient amount of insulin, although the dose given by Dr. Joslin-namely, 80 units in the day-would be con- sidered a large dose under ordinary conditions. The amounts which Dr. Carrasco-Formiguera has used have been very large. Thus in one case in which a carbuncle was present on the neck, no less than 240 units were given on the first day although no food was taken. During the next week 200 units were given each day together with increasing amounts of food. Although the patient recovered in this case, it does not follow that a diabetic patient will always recover from another disease, however well the diabetic condition is handled with insulin When such large doses of insulin are being given it is advisable to have estimations of the blood-sugar made at least once a day if possible and to test the urine for sugar every two or three hours. In an emergency 1 Schweiz. Med. Woch., April 23rd, 1925.
Transcript
1090
Annotations."Ne quid nimis."
POPULATION.
THE population of England about A.D. 1000 wassomething like 1 t millions ; it slowly grew to nearly9 millions in 1801, and then jumped up till it reached38 millions in 1921. A hundred years ago GreatBritain had twice the population of Ireland ; now ithas ten times as many people. Which, Mr. A. M.Carr-Saunders says in a recently published volume,’ is
Ia thing the like of which has, as far as is known,never happened before and will, as far as may beguessed, never happen again. The theoreticallypossible multiplication of mankind is infinitelygreat compared with the available area of landand its utmost imaginable fertility. Birth restric-tion, Mr. Carr-Saunders holds, is a necessity, and thecustoms of primitive peoples show that it has alwaysbeen practised ; the modern mind differs from theancient only in asking for reasons instead of beingcontent with religious or customary sanctions. Theauthor is a classical Malthusian, and his argumentcentres round the proposition that the best numberof people is that which gets the largest return out ofcollective human work and so achieves the highestgeneral standard of material and spiritual life.Nomadic life fills the world with n persons per squaremile, agriculture with 2 n or 10 n, according to itsdevelopment, industrial concentration with 100 nor 1000 n. Whether any part of the world is over-populated or not depends therefore on the controlwhich man can exert over his environment. Thatthis will increase may be presumed ; it appearslikely that the population of this country is reaching,or has already reached, a table condition ; thereis no need for alarm, but a great necessity that thesituation should be studied and understood. Suchis, briefly, the main thesis of a most excellent littlebook. The author states the questions and arguesthem very clearly and gives us one of the best half-crown’s worth we have ever seen. Population,birth control, urbanisation are matters in whicha great variety of people take, and ought to take,an interest ; they are of national and internationalsignificance, and if such a book as this were widelyread we should do away with some of the nonsensethat is talked and printed about them. The bookis short and in places necessarily dogmatic; it gives,however, an admirable survey which will incite thereader to go further and tudy some of the worksgiven in the bibliography at the end, in which,curiously enough, there is no mention of the author’slarger book " The Population Problem," publishedby the Clarendon Press in 1922. On one point onlywould we offer a suggestion. Mr. Carr-Saunderspoints out that nations desire to be big because theyso add to their prestige, because they like as manypeople as possible to be of the same ideals andprejudices as themselves, and because they can moreeasily wave the big stick. He entirely omits thepoint which appeals strongly to the biologist, andespecially the biometrician-that large populationsare more likely than small ones to contain those
exceptional variants on whom the progress andguidance of the world so much depend.
SIGNIFICANCE OF MANY TUBERCLE BACILLIIN THE SPUTUM.
IT is generally assumed that the number of tubercle ’Ibacilli in the sputum is directly proportional to the Iseverity of the disease. Another common belief is Ithat the appearance of these bacilli varies with the Iseverity of the disease, short and homogeneous I
1 Population. By A. M. Carr-Saunders. London: OxfordUniversity Press. 1925. Pp. 111. 2s. 6d.
bacilli being supposed to be indicative of severe
disease, whereas granular and moniliform bacilli aresupposed to be coughed up by patients whose diseaseis comparatively slight. To provide a statistical
verification of these views, Dr. T. Stefani and Dr. J.Stefani,l of Montana, have compared the clinicalwith the bacteriological findings at their sanatoriumin the period 1898-1923. Of the 1430 patientstreated, only 781, or 55 per cent., were sputum-positive. There were 303 patients in whose sputumtubercle bacilli could not be found, and 346 who didnot provide sputum for examination. In 70 per cent.of the 781 sputum-positive cases, the views referredto in the opening sentences of this annotation wereconfirmed. Cases in which the disease was slightwere marked by a paucity of tubercle bacilli in thesputum, cases in which the disease was severe were
marked by the great number of bacilli, and accordingas the patients became better or worse, the numberof the bacilli in the sputum became less or greater.In 8 per cent. these correlations were reversed, andin the remaining 22 per cent. the dwindling or
augmentation of the numbers of bacilli in the sputumbore no uniform relationship to the clinical course ofthe case. A comparison of the appearance of thebacilli with the course of the disease showed that in60 per cent. of all the sputum-positive cases theorthodox teaching held good. When the disease wasslight, most of the bacilli were granular, when itwas severe, they were short and homogeneous, whenthe patient was getting better, granular bacillireplaced the homogeneous bacilli, and when thepatient became worse homogeneous bacilli againappeared. In 18 per cent. these correlations werereversed, and in the remaining 22 per cent. no uniformparallel could be drawn. By combining the twofactors-both the number and the appearance of thebacilli in the sputum-the authors of this interestingpaper show that in as great a proportion as 80 percent. a clue is given by the microscopic examinationto the prognosis. Their painstaking research isconfirmatory of views held for a long time. It is somuch less exciting to confirm than to subvert oldteachings that the authors are to be congratulated onhaving conducted investigations without that incentiveto work which some of us find in the prospect ofproving another in the wrong.
INSULIN AND INFECTION.
THE article in our present issue by Dr. R. Carrasco-Formiguera, of Barcelona, on the amount of insulinrequired in the treatment of the surgical complicationsof diabetes and Dr. G. Graham’s article on the relationof infection to diabetic coma in the current numberof the Quarterly <Tournal of Medicine, both drawattention to the relation of sepsis to diabetes and ofthe necessity of giving an adequate amount of insulin.Dr. Carrasco-Formiguera points out that there is animpression abroad, for which he regards Dr. E. P.Joslin of Boston as partly responsible, that insulinis of little value in the presence of sepsis. He thinksthat this is solely dm to the use of an insufficientamount of insulin, although the dose given by Dr.
Joslin-namely, 80 units in the day-would be con-sidered a large dose under ordinary conditions. Theamounts which Dr. Carrasco-Formiguera has used
have been very large. Thus in one case in which a
carbuncle was present on the neck, no less than
240 units were given on the first day although no foodwas taken. During the next week 200 units weregiven each day together with increasing amounts offood. Although the patient recovered in this case,it does not follow that a diabetic patient will alwaysrecover from another disease, however well the
diabetic condition is handled with insulin Whensuch large doses of insulin are being given it isadvisable to have estimations of the blood-sugar made
at least once a day if possible and to test the urinefor sugar every two or three hours. In an emergency1 Schweiz. Med. Woch., April 23rd, 1925.
1091
it is safe to give large doses of insulin provided thatthe urine is tested in this way and that insulin isnot given when the urine contains no sugar, providedalways that the symptoms and signs of insulinhypoglycsemia are clearly recognised and its treatmentremembered. Dr. Graham also found it necessary togive large doses of insulin, although his maximumdose was only 160 units in the day. The point whichhe has made is the relation of an acute infection tothe onset of diabetic coma. In seven out of nine casesof coma an acute infection was present, but was onlyobvious in two cases on admission to hospital. Intwo cases a definite pathological lesion would havebeen discovered at an autopsy if the patient had diedin coma, while in three cases it is probable that nolesion would have been discovered, since the signs ofan otitis media in one case and of an abscess in theantrum of Highmore in another did not appear untilsome days after the patients had recovered con-
sciousness. These observations show the importanceof searching for an acute infection whenever thepatient shows diminished sugar tolerance or becomescomatose. Dr. Carrasco-Formiguera describes thebeneficial effects which took place in the healing of alarge wound following small doses of insulin, althoughthe diabetic condition was obviously of the mildest.This is a point which needs further investigation, sinceinsulin may prove to be of definite assistance to thesurgeon in the treatment of chronic wounds.
THE TREATMENT OF CHRONIC DRUNKARDS.THE treatment of the chronic drunkard is always
a difficult problem and on the whole the solutionin this country along the lines laid down by theInebriates Acts of 1879-99 seems to be fairly satis-factory, particularly when compared with the stateof affairs in France, for example. In that countrythe number of chronic drunkards is increasing veryrapidly, and Prof. Maurice Letulle last year made astriking appeal for the provision of " drinkers’asylums," 1 where these unfortunate creatures maybe kept under restraint and suitably treated, for atpresent, unless the drunkard is definitely insane orunless he commits some criminal offence under theinfluence of drink, he is given no chance of placing himself under any restraining regime. In Englandthere is likewise no system of compulsory restraintfor the non-criminal drunkard, but there exist certainhomes for inebriates where private patients are
received as well as those who apply for admissionunder the Inebriates Act, and the forty-first annualreport of Dalrymple House, Rickmansworth, whichwe have just received, illustrates effectively thebeneficial results of restraint on these cases of alcoholicaddiction. During the last year 59 patients wereadmitted to this home, 51 as private patients andeight under the Act. All were cases of alcoholic excess,and the absence of drug case admissions is attributedby the medical superintendent, Dr. F. S. D. Hogg, tothe carrying out of the Dangerous Drug Act regulations,which he considers have so reduced the incidence ofcases of habit-forming that further amendments tothat Act are unnecessary. We referred in com-
menting on last year’s report to the fact that theafter-history of 1645 cases showed that 40 per cent.were doing well, and inquiries with regard to theresults of treatment amongst those who have beendischarged during the last few years show that56 per cent. were definitely doing well, excluding thosecases about which no information could be obtained.Dr. Hogg remarks upon the alteration in the symptomsof excessive alcoholism which has taken place withinrecent years, particularly in cases of even moderatespirit-drinking. Toxic symptoms, such as partialblindness, loss of memory, delusional states associatedwith early excitement and slow recovery, are morefrequent than hitherto, and it is suggested that thisis due to the adulteration of whisky with cheap
1 Le Progrès Civique, July 12th, 1924, p. 984.
deleterious alcohols by certain dealers being now amore frequent practice than before the war. Ithas, however, recently been pointed out 2 by Dr. R.Hunt, of the Harvard Medical School, that thetoxicity of " boot-leg " liquors submitted for analysiswas sufficiently accounted for by their content ofethyl alcohol. The beautiful situation of DalrympleHouse, as shown by illustrations to this report, theindications that the social side receives careful atten-tion, the provision of a workshop, &c., all emphasisethat one of the important factors in the treatmentof chronic alcoholism is environment. The otherimportant factor, that of regime, doubtless receivesdue attention at the hands of those who have madea long study of this disorder, but it would beinteresting to know if the hours of meals, forexample, as set out in this report, are rigidlyadhered to, for the 14 hours which appear to elapsebetween dinner and breakfast must feel long to thosewith a morbid craving.
THE FOOD VALUE OF CEREAL FOODS.
IT has long been known that rickets tends to.develop most readily in children fed on diets whichcontain much carbohydrate, especially when th&content of protein is also low. Feeding with con-densed milk has been supposed to be particularlyliable to lead to the development of rickets, and themain lines of treatment now recognised are to increasethe amount of anti-rachitic vitamins, to give plentyof sunlight, and to bring about a proper balancebetween the protein and carbohydrate of the food.Investigations by Prof. E. Mellanby have shown thatpuppies develop rickets most readily when largeamounts of bread are eaten, and subsequent experi-ments showed that the calcification of bone dependson the operation of several factors. These factorshave been recently discussed by him in a Greenbook (No. 93 of the Medical Research Council SpecialReport Series), which was summarised in THE LANCETof April llth, p. 789. In an investigation on thecomparative influence of different cereals on thedevelopment of rickets, he has produced what appearsto be incontrovertible evidence that the carbo-hydrate content of the diet is by no means the onlyfactor concerned. First there is the confirmation ofthe view that when the anti-rachitic vitamin isdeficient, increasing the cereal content of the dietleads to the production of far worse rickets. Nextit is shown that the different cereals show great indi-vidual differences in their rickets-producing effectsunder such conditions, the least detrimental beingwheat, the worst by far being oatmeal-a statementwhich, as our Scottish correspondent pointed out notlong ago, has raised a storm in the porridge-bowl.Prof. Mellanby’s experiments seem to show that thesecereals exert a definite pro-rachitic influence on bonedevelopment, which influence can be wholly or in partantagonised by the anti-rachitic effect of vitamin Aor sunlight. The anti-rachitic effect of cod-liver oilis far greater than that of other sources of vitamin A,though egg yolk and milk are also potent. So alsoare various calcium salts, especially the carbonateand phosphate, when taken with butter. It isclaimed that the pro-rachitic effect of oatmeal,which is exhibited in spite of the fact that it containsmuch more calcium and phosphate than wheat, isdue to the fact that it contains a substance, or ondigestion yields a substance, which exerts a definiteinhibitorv effect on bone formation. The calciumcontent of the diet, provided there be enough calciumfor bone formation, appears to be of secondaryimportance. The essential fact is that, in order to,avoid rickets, the diet must show proper balance,there must be enough calcium and phosphorus, anti-rachitic vitamins must be present, and there must
: not be an excess of the cereal component of the diet,i which would, by supplying a pro-rachitic factor,, oppose the normal growth and formation of bone.
