mortality rate. Malaria constitutes a grave health problem, and its solution is known. To neglect to take advantage of our knowledge as to the methods of prevention and control is to admit indifference or negligence.

The Notification of Pregnancy.-At the November meeting of the American Association for the Study and Prevention of Infant Mortality, A. B. Emmons, of Boston, suggested that the notification of pregnancy to the health authorities should be made compulsory. The purpose of such a law is obvious. It is designed that the notification should be of a confidential nature, but at the same time afford the health officers an opportunity to safeguard the mother and child by securing "proper prenatal and safe obstetric care." It is apparent that a plan of this character, if successfully carried out, would tend to reduce infant mortality and safeguard the welfare of prospective mothers.

It is probable that the desired end could be achieved thru the institution of prenatal work by health authorities and thru the voluntary adoption of the plan by pregnant

women.

Women who desire to have abortions

would have no hesitation in ignoring a law compelling the notification of pregnancy.

The

General laws of a coercive nature are not desirable if it is possible to secure satisfactory results thru other measures. comparative failure in administering the birth registration laws and laws dealing with mortality certification indicates the character of the difficulties which would ensue were compulsory notification of pregnancy to health authorities to be established.

It cannot be gainsaid that a system of voluntary registration of the fact of pregnancy would afford a remarkable opportunity for far-reaching preventive health work. The possibilities of prenatal care, thru the education of pregnant women have been established. A decrease in maternal mortality, and a marked decline in miscarriages, stillbirths, birth injuries, and infant mortality during the first two weeks caused by inadequate obstetric attention are direct results of prenatal care.

The advantages of giving proper treatment to women infected with syphilis or gonorrhea during the childbearing period have long been recognized, and the possibility of extending such medical care would be limited only by the number of women accepting the facilities afforded by intelligent public health agencies. The decrease

with a law of this character, nor would they avail themselves of medical service, if they understood that their medical adviser would be penalized if he failed to make a mandatory notification. Physicians engaged in nefarious and illegal practices, whose consciences are dulled to their duties to the state, their obligations to the profession, and their responsibility to humanity,

marked as the increase in maternal nursing, both constituting a direct advantage to the child and the community.

There are numerous agents already having access to the homes of all sections of large communities as nurses, medical inspectors, tenement house inspectors; and policemen, who could be utilized to distribute the information that prenatal care is

desirable and that the city or rural authorities are ready and willing to give advice, suggestions, and supervision to those desirous of securing it, and who have no regular family medical attendant.

The hospitals and clinics should be prepared to extend their services to the giving of prenatal care to those accustomed to make use of their opportunities.

The value of early medical attention during pregnancy with constantly recurring visitation for examination, instruction, and advice should be disseminated to the homes in every community. Physicians, themselves, should play their part in encouraging women to recognize the protective influences for themselves and their unborn children that are to be secured thru the voluntary acceptance of the principle of prenatal supervision and care.

It is highly desirable that educational methods of this character should be instituted before having recourse to mandatory legislation, which is not likely to be as successful as the compulsory birth notification, which thus far, after years of agitation, has failed to secure general adoption even under the most rigorous state or municipal administration.

Physicians and the Ungraded Children. —In pedagogic circles, the problems of the ungraded class are most interesting and form the basis of a large amount of constructive work. Children in ungraded classes, in general are those who are mentally retarded. Obviously, mental retardation is not necessarily due to an inherent defect, but may arise from physical disabilities affecting the channels of sensation,

which are so essential for the acquisition of knowledge. Brain development is hampered by deafness, diminished vision, or malnutrition, while cardiac defects, dental defects, and diseases of various other portions of the body may interfere with the potential development of the mind.

It is beyond question that the educational and social problems involved in the training and scientific development of mentally retarded children involves the cooperation of the teacher, psychologist, social worker, and physician. No single one of these various types of social agencies suffices to encompass all the knowledge necessary to arrive at a complete diagnosis or plan of action.

It is greatly to the credit of teachers thruout the country that they have been actively interested in the numerous problems of the ungraded children. As a further expression of practical interest, there appears a small journal "Ungraded," which is published by the Ungraded Teachers' Association of New York City. It is interesting to find that the entire editorial force consists of teachers, while the advisory board contains psychologists, psycho-clinicists, active workers in educational psychology, and students of social research. There is only one medical name in connection with the entire publication, and she is an Inspector of Feeble-Minded in Ontario, Canada.

From the standpoint of medicine, it would appear that the work, which the editors contemplate, might be enhanced in value if they were to take advantage of the advice of a few physicians, who might be pyschiatrists, neurologists, or individuals familiar with the ordinary physical disabilities of children. Probably because of the fact that the teachers are accustomed to take advantage of clinics, public and pri

vate, they do not place as high a value upon the relation of clinical medicine to mental retardation as is desirable. It is true that medical examinations are constantly made and medical treatment is instituted in order to correct disabilities, diseases, or defects.

There is a splendid opportunity for cooperation between teachers and the medical profession. The wide introduction of medical inspection in schools, school nursing, home and school visitors indicates the increased recognition of the value of the study of the individual child, with a view to removing those characteristics determining mental dullness or feeble-mindedness.

It is, therefore, all the more striking to find that a magazine of this wide scope, most commendably begun by teachers, should appear to be divorced in its editorial and advisory relations from medicine. The willingness of physicians to cooperate is beyond discussion. The light, which medicine may shed upon the problems of teachers, permits of no argument. “Ungraded" is a welcome addition to the literature relative to feeble-mindedness, but its sphere of influence should be widened and its articles reflect medical as well as pedagogical or psychological opinion.

Herein a further illustration of the necessity of physicians participating in educational work and in making their influence felt in educational circles. Classes for the blind, the deaf, the crippled, the myopic, the trachomatous, as well as for the mentally defective represent types of ungraded classes in which medical counsel is useful and necessary.

Maternal Mortality.-During the past 28 years, the birth rate for England and

Wales has fallen from 36.3 per thousand of population to 23.8. During the same period, the death rate has decreased. Allowing for the increase of population due to immigration, the decennial percentage of increase in the population has fallen from 13.21 (1861 to 1871) to 10.89 (1901 to 1911).

The 44th annual report of the Local Government Board, 1914 to 1915, points out that the death rate cannot decrease indefinitely, while the birth rate may. In view of the sacrifice of numerous sons upon the fields of battle, the importance of checking a fall in the birth rate is apparent. It becomes necessary, therefore, to consider the various factors entering into the mortality of childbearing women.

In the words of the report, “To a very large extent, the same causes operate in producing both excessive maternal mortality and excessive infant mortality in the first few weeks after birth and still more in the antenatal period. **** It may indeed be taken as axiomatic that any influences brought to bear to improve the health of mothers must also influence favorably the health of their infants."

In Scotland, childbearing is a cause of mortality in every 175 registered births, in Wales 179, in Ireland 191, and in England 259. These differences in maternal mortality are due to a large variety of causes. It is regrettable to note that the maternal mortality rate appears to be lower in those communities where midwives attend at the larger proportion of the births. In many towns, the maternal death rate appears to rise in direct proportion to medical attendance as distinguished from the service performed by midwives. Under the English law, this cannot be explained on the basis that unfavorable cases are turned over by

midwives to physicians, because in the instances where this occurs, the cases are still listed as under the direction of the midwife. This, however, is but a single factor in the maternal mortality rate and does not serve as a basis for a satisfactory conclusion, because the study fails to cover a sufficiently large section of the country.

The maternal death rate arises from a complex economic, social, and medical situation which obtains in this country to a greater extent than in England. At the present time, there is insufficient information regarding the relative effects of numerous factors, so that it is an impossibility to single out any one as the most important in causing this most regrettable of all mortality rates. The conclusion stated in the report carries its own lesson.

"General experience, apart from statistical evidence, appears to point to the conclusion that the differences are caused in the main by differences in availability of skilled assistance when needed in pregnancy, and at and after child birth."

There is every reason to believe that the obstetrical facilities of this country are below the standard which should be demanded by a civilized nation. The establishment of maternity clinics, the extension of district obstetrical nursing, the organization of agencies for prenatal care, the improvement. in the opportunities for obstetrical experience of medical tyros, the licensure, supervision, and control of midwives, together with their education, the medical supervision of pregnant women, and the supplying of proper facilities for obstetrical attention at all times form a serious phase in the responsibility of the medical profession for lessening the maternal mortality rate.

During 1914 in the registration area of

the United States, there were 10,518 deaths due to the accidents of pregnancy and the puerperal state. This is a maternal mortality rate of 15.9 per hundred thousand population. Here is a problem involving a death rate higher than that of typhoid fever, measles, scarlet fever, whooping cough, acute endocarditis, diabetes, or suicide.

If we were to regard the maternal mortality as occurring during a single month or two during the year, the nation would be aroused by the idea that a tremendous epidemic had fallen upon the country, and adequate means would immediately be adopted to attack it. Maternal mortality is not merely a dysgenic force in the community, but it is a fundamental destructive condition which decreases the development of the nation. Here is a serious subject of inquiry meriting investigation and research by thoughtful clinicians, laboratory workers, obstetricians, and our ever faithful general practitioners.

Diphtheria Control.-Knowledge as to the methods of prevention and cure merely possess academic interest unless the facts are utilized in public health work. A demonstration of the truth of this is evidenced in a Statistical Study of Diphtheria by F. S. Crum, a paper read before the Vital Statistic Section of the American Public Health Association.

While it is undoubtedly true that there is an annual saving of at least 250,000 lives thruout the world, as a result of the introduction of antitoxin, the diphtheria death rate is still responsible for about 4 per cent. of the total mortality of children under the age of 15 years.

With the annual number of deaths from diphtheria greater than that resulting from scarlet fever, measles, or whooping cough, it is evident that physicians have not taken. complete advantage of the worth of antitoxin in the prevention and cure of diphtheria. There is every reason to believe that diphtheria, as a disease, has not decreased and is endemic in most of the countries of the world, with occasional periods of epidemic occurrence.

The control of diphtheria is difficult, owing to the existence of a large number of diphtheria carriers, whose presence is not suspected and whose wanderings are difficult to supervise or restrict. If, however, the Schick test were more generally employed in order to determine the children susceptible to this infection, it would become possible to immunize a large portion of the susceptible child population and thus reduce materially its incidence.

The attack and mortality rates are highest during the second, third, and fourth years of life, and it is during this period of the pre-school age that children are not under general observation by any organized protective agency. It should be a part of the duty and responsibility of those responsible for the control of institutions for children, whether orphan asylums, day nurseries, milk stations, or convalescent homes, to endeavor to determine the susceptibility of the visitants or inmates to Klebs-Loeffler infection.

During the five year period, 1910 to 1914, 62.2 per cent. of all the deaths from diphtheria and croup occurred at ages under five years. This indicates the necessity of attacking the diphtheria problem during this period of infancy and early childhood.

The greater the density of population, the more frequent the opportunity of attack,

and the more rigorous should be the measures taken for controlling this serious condition, which leaves in its trail paralyses, heart disease, and numerous other incapacitating sequelae.

It is an unfortunate commentary upon the rapidity with which new discoveries are accepted and put into active practice to realize that with the increasing facilities for prompt bacteriological diagnosis, with a knowledge of the importance of the early administration of diphtheria antitoxin, with an increasing weight of evidence as to the value of the Schick test for determining susceptibility, together with the known benefits of immunizing doses of antitoxin, that diphtheria, as a disease, still maintains an undesirably high incidence and death. rate thruout the world.

While the mortality rate, in the United States, has been gradually decreasing from 1900, the existence of a death rate of 17.9 in 1914 is far higher than is warranted in the face of the degree of preventability of the disease. It is a higher death rate than that of typhoid fever, whooping cough, influenza, diabetes, meningitis, malaria, measles, scarlet fever, dysentery and numerous other diseases, in which modern medicine has attained even less adequate knowledge of the methods of prevention and control.

It is of the utmost importance that health departments, state, county, or municipal, provide a complete program for attacking diphtheria. The continued existence of high incidence and mortality rates betokens a lack of administrative accomplishments, which at least calls for inquiry, investigation, and stimulation to greater and more systematic methods of attack upon the diphtheria problem.