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EPILEPSY AS A SOCIAL PROBLEM.

THE LANCET.

lONDON: SATURDAY, SEP1"NMBER 15, 1928.

ALTHOUGH there are probably few diseases which ILave been recognised for a longer time and aboutwhich more has been written than epilepsy, it has tobe admitted that as a social problem it has hithertoreceived comparatively little, and certainly quiteinadequate, consideration. For this reason the twoarticles which we publish in the present number, theone (p. 568) on the results of a census made in Surreyand the other (p. 545) on the subsequent history of anumber of children who have passed through a resi-dential school, are worthy of careful attention. Tothose who are unaware how scanty are our statisticsof disease which does not concern the sanitary or theburying authorities it may come as a surprise to learnthat there are no reliable figures as to the incidenceof epilepsy. Moreover, in view of the wide differencesin the frequency of attacks, the great variations intype and severity which undoubtedly result in manycases being unrecognised, and the fact that epilepticattacks not uncommonly occur as a complication orsymptom of some even graver and more urgentcondition, it may safely be said that it would beimpossible to obtain any complete and reliablestatistics regarding the incidence of the disease. ThePermanent Committee on Epileptics did not attemptthe impossible. They limited their census to a definitearea-namely, the county of Surrey-and to suchpersons as were chargeable to public authorities.They found that in the area examined the proportion iof such epileptics amounted to 0’65 per 1000 of thegeneral population, and, if this may be accepted asa fair sample of the country as a whole, they estimatethat in England and Wales there are 25,000 personsaffected by this disease who are a public charge. Ofthis number rather more than one-third-againjudging from Surrey experience-are mentally normal,whilst the remainder are either insane or mentallydefective. It is clear, therefore, that from the pointof view of incidence alone the problem of the rate-supported epileptic is a serious one. It becomesthe more so in view of the facts ascertained by theCommittee that one-quarter of the total number ofeducable epileptic children are attending no school orinstitution, and that of those who come within thescope of, and should be dealt with under, the MentalDeficiency Acts, less than one-fifth are in fact so

dealt with.No doubt when epilepsy is complicated by, or has

induced, serious mental defect or deterioration there islittle likelihood of the sufferer being rendered economic-ally useful; but there are many young mentallynormal epileptics who drift into chronic unemploy-ability for want of proper education and training, andthere is every reason to believe that the absence ofsuch care is also an important factor in bringing aboutmental deterioration in a number of cases. Dr. J.TYLOR Fox, medical superintendent of LingfieldEpileptic Colony, in his account of the after-history of- 332 children who passed through the colony in a periodof eight years, shows the benents which may resultfrom training in a suitable residential school. Althoughthe children admitted to Lingfield are a worse thanaverage group, inasmuch as they suffer from

attacks are too severe to allow of them attendingordinary schools, their subsequent history shows that28 per cent. of the total have become partly or

entirely self-supporting. When the unpromisingnature of the raw material is borne in mind this resultmust be considered as very satisfactory and as demon-strating the value of the treatment and trainingreceived. Unfortunately, the accommodation at

present existing for cases of this kind is so inadequatethat these advantages are only available for a

relatively small number. Dr. Fox estimates that theproportion of

" educable " epileptic children who areaccommodated in residential special schools is onlyabout one-fifth of the total in existence, the remaindereither drift into pooi-law or other institutions or theyare allowed to remain at home. In any event it maysafely be said that the great majority of them receivelittle if anything in the nature of skilled treatment andtraining. In addition to this, as we have alreadymentioned, the accommodation available for those inwhom the epilepsy is accompanied by mental defectis equally unsatisfactory. A careful study of the factspresented points conclusively to the serious nature ofthe problem, and to the utter inadequacy of the

existing accommodation for the epileptic, whethermentally normal or abnormal. It may be that someof these matters will be dealt with by the Board ofEducation Committee on Mental Deficiency nowsitting, whose report, we understand, will be publishedbefore the end of the year. It may also be that someattention will be given to the problem in the altera-tions to the poor-law system which are imminent. In

any case, however, it cannot be doubted that epilepsyconstitutes an important social problem, and that thetime has arrived when it should receive seriousconsideration from this aspect.

THE FALLING BIRTH-RATE.THE birth-rate for 1927 turns out to have been the

lowest recorded in this country since the establish-ment of civil registration, and responsible citizenshold up their hands in horror, wondering what theyoung people are coming to. A sane view of thesituation suggests that there is nothing to be horrifiedat except the spectacle of human beings respondingto their environment in the same way as any otherlive thing, animal or plant. Large and increasingpopulations have been welcome in the past for tworeasons. In the first place, they provided largerarmies-a consideration which was perhaps natural inOld Testament times and was artificially flogged .intoprominence in Europe as late as the nineteenthcentury ; it has now, we hope, gone for good. And inthe second place, rulers and governors realised thatlarge numbers are more likely than small ones to

comprise those extreme variants in qualities of body,mind, and spirit on which leadership depends so

much. We have, too, in the last 150 years become soaccustomed to seeing the population of this countryprogressively growing larger and larger, and to hearingcontinually that there is a shortage of houses thatwe find it difficult to realise the possibility-indeed,as far as can be foreseen, the certainty-that ournumbers will very soon cease to increase and that the

population will return to the stationary position whichit had, at a much lower absolute level, in the sixteenthand seventeenth centuries. Even the town-plannerand the speculative builder do not seem to haveappreciated the position.

If people really believed in evolution, they wouldhave more constantly in mind the thought that mail

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is the product of his ancestry and that he is likely inmatters of large temporal importance to behave inways analogous to theirs. The numbers of any animalor plant which are alive in any given area at anymoment are the maximum which conditions allow.

Breeding is actually or potentially profuse enough tokeep the place as full of a particular species as it willhold ; with plants it is generally a question of space,with animals of food. And so long as conditionsremain unaltered this optimum population persistsat the level which allows the greatest number ofindividuals to exist at a fairly high level of perfection ;natural populations of animals and plants do not

consist of starvelings but of individuals which arewell grown, healthy, and reproductive. There is, inshort, no striking evidence in the survivors that thereis any injurious overcrowding. But if conditions alter,the optimum population changes too ; the dandelionand other weeds of bare soil exist on the minor

catastrophes of the earth’s surface and the rat

population varies directly with the available food-supply. Man needs space and, being animal, especiallyfood, and under any given set of conditions he

multiplies till the number of human beings is the

largest which can obtain the return from life whichthey are prepared to accept as adequate. In com-

parison with smaller animals lie reproduces slowly,but given time he will fill up any conditions in whichhe finds himself. He differs, of course, from animalsin that he can to some extent make his own environ-ment-though animals are not wholly without thatcapacity-and to that extent he can control his ownoptimum population. It is here apparently that

anthropoid apes fall short. With, at any rate in theorang and gorilla, exceptional physical powers theylack the mentality to alter the circumstances of theirlife in such a way that they can be numerous. Theyare, in fact, all sparse ; it was, we think, Sir HARRYJOHNSTON who estimated that there were not morethan 10,000 chimpanzees in equatorial Africa andthe larger ones are fewer still. We may guessthat early man was hardly abundant by modernstandards ; conditions of life must have been veryhard, and it was perhaps just a lucky chance thatenabled him to multiply enough to reach the stagewhere by numbers and herd action he could have themastery over other beasts. And it is most interestingto note, as Prof. CARR-SAUNDERS has pointed out,how primitive man always regulates his numbers tothe available food ; profuse procreation seems to havecome in with the Christian era and among savagesthe production of children is, as a rule, severelyrestrained, partly by rules and customs, partly by asheer lack of fertility to which attention has oftenbeen drawn lately in the South Sea Islanders. Asman’s control over his circumstances developed andincreased, so larger populations became possible andwhere and when possible they were automaticallyachieved. The flood of new people which flowed inthis country all through the nineteenth century wasthe product of the changes known as the industrialrevolution ; the flood has slackened some time sinceand will soon come to a standstill unless some

undreamed-of expansion in the facilities of life isdiscovered. Theoretically, a further growth of popu-lation might occur if the standard of living requiredwere reduced. But it is very doubtful whether thisfactor is really capable of any deliberate control.The indefinable " adequate return " is not luxuriousphysical ease but the state in which a man can dobest with his mind and body ; " motor-cars versusbabies" applies only to a negligibly small part ofthe population ; the ordinary run of men have derived

from their animal ancestors a far finer sense of

cooperative life.It follows, as Dr. F. A. E. CREW pointed out in his

thoughtful address at the British Medical Associationat Cardiff (reported at some length in our issue ofSept. 1st, p. 463), that we must look much furtherthan the boom in frank contraception for our explana-tion of the diminishing birth-rate. The birth-rate in.

England began to fall 50 years ago in obedience tothe principles of populative growth which, as PEARLhas pointed out, apply to yeast cells and the flyDrosophila as well as to Spaniards and Dutchmenand Frenchmen and any live thing else. It hascontinued to fall along the predicted lines and, whetherwe like it or not, in the absence of some paroxysm ofcivilisation our numbers will soon cease to increaseany further. Deliberate birth restriction may behaving a good deal of effect in these, the later, stages.of the process, but the main explanation is inman’s unconscious or subconscious adjustment to his.environment, in his animal response to circumstances.Those will view the Registrar-General’s figures withthe greatest calm who believe with the authors of the.Bridgewater Treatises that the world is constructed.in the best possible way.

COMPENSATION FOR SILICOSIS.COMPENSATION for the occupational disease silicosis-

is more complicated than for other diseases on account.of the long latency and chronicity of the complaint.It has so far only been granted in Great Britain andsome of the overseas Dominions. South Africa, withregard to the Rand gold mines, was the first to act,and there prevention and compensation are closelyinterlocked. Thus any miner who develops ordinarypulmonary tuberculosis is suspended from employ-ment in order to exclude infection from the otherminers, and is compensated. In England action was.taken first on somewhat similar lines in 1918 under ascheme applied to the small refractories industriesThenceforward use of the legislative powers takenwas delayed until 1927 when compensation was

granted to metal grinders, but the somewhat com-plicated procedure adopted in the refractories’ schemewas then abandoned. At the same time a scheme forthe pottery industry is in preparation. Action 011

these lines, however, is proving wearisomely pro-tracted ; and every year men are succumbing to this-acceptedly occupational hazard in such importantindustries as stonemasonry, granite-cutting, quarrying,.and metalliferous mining, without any compensation.The Home Office has now abruptly altered its policyof proceeding industry by industry, and has just,issued a comprehensive draft scheme for grantingcompensation for death and total disablement io-

practically every occupation in which the silica riskexists. Even men in coal-mines driving hard headingsor sinking shafts through sandstone rocks are to be-included, also millstone builders and abrasive soap-makers, as well as the crafts named above. The-

plan of insisting upon periodical medical examina-tions, and upon suspension with compensation ofthose showing early signs, is abandoned. Com-pensation is only to be granted for total disablementor death. At the same time, while proposing thus taaward compensation which is clearly overdue, the-

Ministry announces the intention to examine in due-course each industry affected in order to link up-preventive procedure with compensation awards.This procedure is likely to lead rapidly to limitation.of the silica hazard. It will have an indirect economic: