the imagination can possibly conceive a fracture of this bone without some associated damage to the surrounding structures. The more extensive that damage, the greater the separation of the bone fragments, the less the liability to spontaneous functional recovery. From the diagnostic standpoint, it is important to determine, if after falling, the patient got up, or if he made any attempts at walking. Attempts on the part of the patient to arise determine further lacerations of the parapatellar ligaments and consequently further separation of the fragments.

Upon the proper repair, upon the proper reunion of these soft tissues is dependent, in an important measure, the functional integrity of the knee-joint. Andrews states that the patellar union is only an incident in the ligamentous and tendinous repair by suture. So important is the approximation of these torn tissues, so essential is the restoration of the continuity of the aponeurotic fibres of the vasti, of the rectus femoris and of the deep fascia of the leg and thigh, that many operators in the treatment of fractured patellæ limit all their suturing to the torn soft tissues.

Prolapse of the Prepatellar Tissues into the Breach.

This prolapse of the prepatellar fibrous tissues between the fragments of the fractured bone is one of the important obstacles to non-union. The prevention by these intervening soft tissues of the exact apposition of the fragments is one of the most valid reasons for resorting to the open operation. When present, these interposed soft tissues constitute an obstacle to osseous union, removable only by the open operation.

This fibro-periosteal curtain may overlap the fractured surface of either fragment. In some cases both fractured surfaces are either pretty or completely covered by this prolapsing prepatellar tissue. These prolapsed tissues may be easily removable, may be hooked to the underlying bone. When hooked to the fractured surfaces, their removal, at times were attended with some difficulty. In many fractures of the patella, be they tear or blow fractures, or due to both factors, the prepatellar bursa is contused. Blood and portions of the prepatellar bursa can enter into the formation of the prolapsed prepatellar curtain, being superimposed upon the aponeurotic tissues.

By the aid of the open operation all interfragmentary soft tissues are easily removable. Bony union presupposes an exact apposition of the osseous surfaces. Blood interposed between the fragments, we do not consider as a foreign body, it being well known that between fractured surfaces the presence of blood is constant. Intervening tissues of other description act as foreign bodies and are productive either of fibrous union or of non-union. We concede that massage relieves pain, promotes the circulation and aids in the removal of exudates, but can it accomplish anything towards the removal of soft tissues that have prolapsed in the breach between the fragments? The attempt to remove the

interfragmentary soft tissues by rubbing the fractured surfaces one upon the other is illusory. Interposed soft tissues can be removed only by means of the open operation.

(To be concluded in the July number.)

INFANT MORTALITY-ITS CAUSES AND PREVENTION.*

BY FRANCIS H. MACCARTHY, M.D., Boston, Mass.

The subject which I am about to bring to your attention covers a wide field, and there are certain phases which I cannot hope to consider in a paper of this length-therefore, I hope the omissions will stimulate profitable discussion.

Undoubtedly you are all more or less interested in the subject, for it is attracting the earnest attention of students of medical sociology both in this country and abroad. Two large books have been published in England, and some excellent papers have appeared in the medical journals of this country. The American is apt to think that all good things have their beginning in America, and the loyal British subject claims the utmost prestige for all English institutions, but in this matter the United States as a country has been backward, for it is only during the last two or three years that there has been systematic study of the question of Infant Mortality, its causes, its prevention and adequate birth registration.

In European countries the question has long been recognized as a matter of the greatest economic importance, and has been studied very exhaustively, especially by the governments of France and Germany, where there is a steadily declining birth rate. Nor can we congratulate ourselves that the birth rate in the United States is holding its own. While the decline is not so apparent in our country, owing to a steady inflow of foreigners, there is a marked. decline in the birth rate outside of the congested districts.

During the last few years, however, the United States has been trying to make up for lost time, and some very definite movements have been set on foot for the study of the causes and prevention of infant mortality. The Russell Sage Foundation in its Department of Child Hygiene, and the Clark University society known as the Child Conference for Research and Welfare, are doing work of the greatest value, while in November, 1909, the interest of medical men culminated in a conference at New Haven, the outcome of which was the formation of a new national society, and the American Association for Study and Prevention of Infant Mortality held its first annual meeting at Baltimore in November, 1910.

Back of all this interest there must be some strong purpose. Put into simple English, it may be said that we are losing too many young children in this country, out of all proportion to the birth rate, and that we are face to face with a serious social problem.

*Read before the Massachusetts Homoeopathic Medical Society, April, 1911.

Let us isolate from columns of statistics a few of the figures. They are somewhat impressive. Quoting from the Mortality Report just issued by the Bureau of the Census for 1910: “Of the total number of deaths that occurred in 1909 (732,538), no less than 196,534 were of children under five years of age, and 140.057 were of infants under one year of age." These figures show that the deaths of infants under one year of age constituted nearly one-fifth of the total death rate in the registration area for that year, or one death out of every five is that of a baby less than a year old. Consider that the registration area includes only about half of the total population of the country, and we can judge somewhat of the extent of this waste.

To bring the matter nearer home, quoting from the latest available figures, of the total number of deaths in the city of Boston for 1909, something over 11,000, 3000 were of children under five years of age, and over 2000 were infants under one year of age. It is estimated by Prof. Fisher of Yale that 47 per cent., or "nearly one-half of the diseases of infancy of the median age of one year are preventable." There are those who consider this estimate as very conservative.

Now, it would be discouraging indeed if, in spite of all the various preventive measures instituted during the last ten years, no apparent decrease in the infant death rate could be recorded. Up to a very recent date this was the opinion held by some of the men interested in the subject, but during the last few years in this country at any rate, we are beginning to see some result of good work, and the figures would seem to indicate a decrease. In the latest Massachusetts Registration Report for 1910 the ratio as compared with the number of births of 12.72 per cent. is the lowest for twenty years. A decline is also plainly indicated in the latest report of the State Board of Health. The most accurate method of estimating infant mortality is comparison of the death rate with the birth rate, and although some authorities claim the decrease is owing to a decline in the birth rate, the latest available figures from several sources clearly indicate a decrease in infant mortality.

It may be questioned by some whether the saving of thousands of infants will not interfere with the law of the survival of the fittest, and tend to the survival of the unfit-that is, if thousands of weak lives will not be prolonged only to fall by the wayside when weakened by the wear and tear of adult life. This is certainly a pertinent question, and tends to make one thoughtful, but it may well be answered by calling attention to the unhygienic habits which characterize adult life. Hygiene must not stop with infancy and childhood. We are a wasteful nation; men are not only living beyond their financial income, but are wantonly spendthrift when it comes to their powers of physical and mental endurance. Thus we see a people wasteful of human conservation at both periods of life. Is it any wonder, then, that thousands fall by the way from the effects of degenerative diseases at middle life?

Right here a few words might well be said in regard to the contagious diseases of childhood. We know that these diseases often leave in their wake a crippled heart, weak lungs and damaged kidneys. I am beginning to believe that this aftermath of weakness effects very materially the mortality statistics of middle life, and that the marked reduction of diphtheria and scarlet fever especially, which has been accomplished of recent years, must eventually reduce the number of deaths at middle life.

A very important point which looms up out of this whole question, it seems to me, is that the same diseases or causes or diseases, which tend to destroy the life of the weak child, also tend to undermine the health and retard the development of the strong child. Therefore, if we can improve conditions which surround infancy. and thus save weak lives, we shall at the same time be carrying out improvements which will tend to prolong and fortify the lives of the strong.

Causes of Infant Mortality.

When we come to study the causes of this loss of infant life, we are impressed at once with the fact that these causes are many and complex, and that any thorough study of the subject must not only concern itself with some consideration of the direct causes of death, such as appear on the death certificate, but that the investigation must lead one into the realm of the sociologist, for back of the direct causes are those underlying evils which are so largely productive of the ills of society in general.

Briefly, then, let us consider for a moment the direct causes, giving each its relative importance. Undoubtedly the most important factor in loss of life during the first three months is the feeble resistance of infancy, about 25 per cent. of the whole number of deaths occurring during the first month, and 48 per cent. during the first three months. The causes are prematurity, malformation, injuries at birth, syphilis, effects of alcohol and vice. By far the greatest fatality during the remainder of the first year is caused by diarrhoeal diseases, the percentage being variously estimated in different cities from 28 per cent. to 31 per cent.

Next in importance as causative factors are pneumonia, bronchitis and influenza with a mortality of 20 per cent., while the four principal contagious diseases, whooping cough, measles, diphtheria and scarlet fever, cause something over 3 per cent. of the total.

We have thus enumerated what might be designated as the most important direct causes of death, but back of the causes which are given on death certificates, are the fundamental causes which tend to weaken vitality, to increase the natural feebleness of infancy, and thus prepare a favorable soil for the propagation of disease. To me these causes seem the most important, since they represent in a very large measure, the real conditions which underlie the loss of infant life, and are also concerned with the mortality of later life.

When something like 2,000,000 infants die in a country during a decade, it would seem to be indicative of rotten threads running through and weakening the social texture. Indeed, I feel that I am not stating it too strongly when I say that a steadily lowering birth-rate, and a high infant death-rate must certainly indicate the presence of depraved conditions inevitably. tending toward decadence in national life.

About 24 per cent. of the deaths occurring during the first two or three months are due to prematurity, or feeble resistance. Then there are certain malformations of the heart, brain and other organs, which render proper development and life of the child impossible. Now these are regarded as "unfit," that is, in plain language, their continued existence is not considered desirable, and, of course, this would seem to be right, since the future of such children would be miserable at the best.

It should be noted, however, that back of many of the deaths due to prematurity and feebleness at birth are such factors as alcohol, vice and syphilis, and that there is some possibility of these deaths becoming preventable.

The two most important underlying conditions are poverty, and ignorance, two enemies of right living which seem bound to accompany all civilization. Any successful effort to combat this. loss of infant life must take these into consideration. It has been estimated that in wealthy families the mortality of the first year is 10 per cent., in the middle class 21 per cent., and the laboring class 32 per cent. It is stated by Hale that of 170 infants dying of acute intestinal disease in 1903 and 1904, there were 161 children of the poor, nine among the well-to-do, and none among the rich.

For the children of the well-to-do and the rich money buys good food, sunny living rooms, the best of nursing and medical care. Life for the children of the poor is a constant struggle for existence in wretched surroundings and under the poorest conditions of over-crowding in dark, sunless rooms, insufficient and unsuitable food. Mothers work late into pregnancy and while nursing their children; they know little in regard to hygiene, and indeed, could not follow it out if they did know. Add to these, lack of sufficient nourishment during pregnancy and also while nursing, and absolute inability to change conditions, such as obtaining sufficient fuel in winter, also to avoid excessive heat in summer, and to change environment-such are the results of poverty, and the sacrifice of infant and child life must inevitably follow in their wake, for under such conditions do the two great causes of infantile mortality thrive.

The death rate from intestinal diseases is the direct result of faulty feeding, congestion of city life, and excessive heat, and as we know, thousands of children die during July and August each year. It is the causes working together which produce the fatal results. While city life is not desirable, if children are given