The invitation to comment on a paper that reports changes which occurred during a period that coincided, within a year or two, with my career as a consultant paediatrician presents me with an irresistible temptation to reminisce. At medical school in the late 1950s I learned that pneumonia, one time captain of the men of death, had responded dramatically first to sulphonamides and then to penicillin, but that some deaths were still “inevitable”—a phrase much used at that time to excuse our inability to manage conditions that we did not fully understand. Asthma was common in children but was considered to be an unusual cause of death, although it was responsible for the first death I encountered as a paediatric senior house officer. In the minds of my teachers asthma was readily distinguished from bronchitis and, to this day, I can replicate a table listing the differences between asthma and wheezy bronchitis, most of which has—to my surprise—turned out to be accurate.¹ In those far off days most children with cystic fibrosis (CF) died in the pre-school years; Pseudomonas species were not the problem they are now and most children died while still colonised with Staphylococcus aureus or Haemophilus influenzae. Bronchiolitis was considered to be rather an esoteric diagnosis for which there was no diagnostic test – it would be a few years before its association with the respiratory syncytial virus (RSV) was appreciated.² It was thought safer to diagnose pneumonia if crackles were prominent and to treat the child with antibiotics, while those with predominant wheeze were labelled “bronchitis” and given ephedrine.

In the mid 1960s I extracted data from the Registrar General’s annual reports when, as a junior, …