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The trend of diphtheria
PUBLIC HEALTH, October, 1945 dysentery for 1939-44 were 1,963, 2,843, 6,597, 7,177, 7,772, 10,150. During the first half of this year 10,006 cases were notified. T h e majority of cases are of the Sonne type, and it is probable that the notifications are only a proportion of those actually occurring. Other forms of illness caused by infected food are not notifiable, but it appears that they are now more common than formerly. Trichiniasis appeared in several localities in the early war years and outbreaks due to staphylococcal, Salmonella, and other forms of food poisoning have been rather frequent. T h e general relaxation of standards of cleanliness and the increased risk with communal feeding have been largely responsible for these gastro-intestinal infections. T h e continued increase in scabies, despite energetic measures to combat it, was a cause of concern to many public health authorities, and this disease has been made notifiable in many areas during the war. T h e w h o l e of the increase cannot be attributed to war conditions. During the war of 1914-18 there was a rise ascribed to the infection of soldiers returning from France. Among the London school children a continuous improvement, after the war peak, was noted until 1925. From 1926 onwards there was a progressive worsening of the position, and in the ten years preceding the last war the incidence had i0creased fourfold although the number of children exposed to risk had decreased by onefifth.
The Trend of Diphtheria Mortality from diphtheria has fallen steadily since the great outbreak in" the last years of the 19th century. T h e deathrates per million children at ages under 15 years fell from 888 in 1901 to 310 in 1938. While this was a substantial improvement, it was nevertheless disappointing in view of the fact that, of the infectious diseases of childhood, diphtheria was the one in which the facts of aetiology was first obtained and knowledge was most complete. I n the immediate prewar years about 3,000 children died annually from this disease. At ages five to ten deaths from diphtheria exceeded in number that from the next two most important causes of death combined. T h e experience of some American and Canadian cities, over 20 years, showed a drastic reduction in mortality after the introduction of active immunisation, and led the Government in 1940 to offer a proved prophylactic free to all local authorities. Previous to this, immunisation h a d been carried out by only a few local auth6rities. T h e campaign for mass-immunisation met with varying success within the country. In some areas almost the whole of the child population had been inoculated by 1942, but for the country as a whole the proportion was not quite one-half. At one period there was a danger that even this proportion would not be maintained, but a further campaign was launched with the object of raising the percentage of immunised children to at least 75. During the last two years the drop in notifications shows that material progress is being made in the reduction of the incidence of this disease. T h e annual numbers of cases of diphtheria notified in England and Wales for 1937-44 were 61,870, 65,720, 47,910, 46,683, 51,091, 42,318, 35,944, 29,446. Judged from these figures the incidence is now approximately half the pre-war level, but it is probable that the reduction is actually greater than this, as there is evidence that the diagnostic error has risen during recent years, due to a greater readiness to send suspected cases to hospital. Until June of last year no correction was made in the returns for the error caused by including these suspected cases, which, after observation in an isolation hospital, were diagnosed differently. Mortality from diphtheria has decreased at a greater rate than the incidence : the annual deaths during 1940-43 were 2,481, 2,641, 1,827, and 1,371. T h e notifications in 1943 were threequarters of those in 1941, while the deaths were halved during this period; or, expressing the deaths as a ratio per 1,000 notifications, the proportions were 53, 52, 43, and 38 during 1940-43. T h e decrease in the ratio of deaths to notifications is influenced by the differential death-rate experienced by the non-immunised and immunised children. T h e returns of
local authorities during the first half of last year showed that 2,243 cases of diphtheria with 16 deaths occurred among the immunised children, and 6,743 cases and 368 deaths among the non-protected children. These figures give the chance of a diphtheria patient's dying as eight times greater among the non-immunised than among the immunised. If. the difference in the liability of the two groups of children to contract diphtheria is taken into account, then the chance of dying from diphtheria is at least 25 times greater among the non-immunised than among the immunised group. T h e notifications of diphtheria during the present year have again improved, and at present are only three-quarters of those for the corresponding period of 1944. T h e seasonal rise in incidence during the winter months, which has been a feature of diphtheria, was not maintained in the first weeks of this year. The result of this change in the trend was that the notifications during the first 12 weeks of this year were less than the number reported during the 12 weeks of last summer, when diphtheria was at the lowest level ever recorded until t h e n : lower weekly totals than last year's m i n i m u m have been recorded this summer. Considerable differences existed in the geographical distribution of diphtheria in the pre-war years. It was highest in the northern region and lowest in the eastern and southwestern regions. The geographical differences have shown a relative increase, because the recent decline in incidence has not been uniform throughout the country; the north has lagged behind, and now has a relatively higher proportion of the total cases than a few years ago. I n 1940 the combined counties of Cheshire, Lancashire, Yorkshire, Durham, Northumberland, Cumberland, and Westmoriand contributed 40% o f the total notifications, while in 1944 the percentage was 54. This section of the country and Wales were the only areas in which relatively large local outbreaks of diphtheria have been recorded in recent months. T h e largest of these outbreaks were in Caernarvonshire, Bangor M.B., where the notifications rose from four to 55 in one week, and in Yorkshire, Vehitley R.D., with an outbreak involving 24 persons in one week. T h e north differs from the south in type of infection, the available data suggesting that gravis infections are more common in the former. Although the prevalent type of diphtheria varies between adjacent areas and from one season to another, the distribution for the whole country has remained remarkably constant during the past four years ; the gravis type constitutes about one-half of the total, and intermedius is slightly more frequent than mitis. T h e changing distribution of age of attack was a feature of the pre-war experience : the shift was from pre-school to school ages. Official statistics do not permit of a comparison of notifications by age before June, 1944, so that the effects of immunisation on age distribution cannot yet be determined ; but the reports of Medical Officers of Health suggest that the age of attack has increased and adolescents and adults form a much larger proportion of the cases than in the prewar years. T h e success obtained by the immunisation campaign in depressing the incidence of diphtheria to the lowest level ever recorded should give encouragement for further efforts, Unless the proportion of young children immunised is maintained a few years births will yield a child population in which the immunised are in a minority. A n n u a l Luncheon Many members and a large number of distinguished guests had the opportunity at the first peace-time annual luncheon of the Society of making the acquaintance~ of the new Minister of Health, Mr. Aneurin Bevan, who, although he expressed a wish not to have his speech reported, made no observations about the new G o v e r n m e n t ' s plafts for a National Health Service. He was listened to with appreciation punctuated by applause, and it was obvious that he quickly and easily captured the good will of those who were present. T h e only other speech was that of the President of the Society, Prof. R. M. F. Picken, who proposed the toast of the guests. Among those he welcomed were Mr. C. W. Key, M.P.
PUBLIC HEALTH, October, t945 (Parliamentary Secretary to the Ministry of Health), Sir John Maude (Secretary of the Ministry of Health), Sir George Martin (Association of Municipal Corporations), Mr. W. L. Dacey (County Councils Association), Mr. E. P. Everest (Rural District Councils Association), Mr. D. M. Watson (the Royal Sanitary Institute), and Alderman W. E. Mullen (Mayor of Holbom). Mr. D. J. Jones (Urban District councils Association) was unfortunately prevented from being present. T h e President then extended a welcome to his medical colleagues, including the Presidents of the Royal Colleges, the President, Chairman, and Secretary of the British Medical Association, the President of the General Medical Council, and the Editors of the Lancet, British Medical Journal, and Medical O.fflcer. Prof. Picken spoke of the origins of the public health service and the Society nearly a hundred years ago, and the increasing part taken by its members in promoting the health of the people. He acknowledged, however, that 'the other branches of the medical profession had helped greatly to create the atmosphere necessary for public health progress. I n its views as to the future of medicine, the Society was largely in accord with the rest of the profession except that it believed that local authorities must continue to play an important part in administration. When the form of any new medical service was under consideration, it might prove worth while for the planners to study both the attractions and the repulsions to those engaged in the type of service represented by the Society. Prof. Picken assured the Minister of the support of the Society in accomplishing the great tasks which lay ahead of him. The Northern Ireland Minister of Health and Local Government has appointed a l~ental Health Services Committee under the Chairmanship of Lieut.-CoL A. R. G. Gordon, D.S.O., D.L., M.P., to advise on questions of a specialised nature in connection with mental health services. The Committee is representative of mental health services throughout Northern Ireland and will work in close co-operation with the Health Advisory Council. Any recommendations made by the Committee will be considered by the Council in the first instance, so that they can be fitted into the general plan now being worked out for Health Services of Northern Ireland as a whole. In particular, the Committee will be asked to give its views on the steps to be taken to make provision for the care and supervision of mental defectives, especially children. The Chadwick Trustees have arranged the following public lectures, admission free. On Tuesday, October 30th, at 2.30 p.m., in the Livingstone Hall of the London Missionary Society, 42, Broadway, Westminster, London, S.W.1 (opposite St. James's Park Station), Dr. W. P. Kennedy will speak on health education. On Tuesday, November 13th, at 2.30 p.m., at the Royal Sanitary Institute, 90, Buckingham Palace Road, London, S.W.1, Mr. F. C. Vokes, engineer to the Birmingham Tame and Pea District Draining Board, will deliver the Bossom Gift Lecture on the modern system of sewage disposal. The Malcolm Morris Memorial Lecture will be g~ven by Mr. Archibald M. H. Gray on Thursday, November 29th, at 2.30 p.m., in the Sir Edward Meyerstein Lecture Theatre, Westminster Hospital Medical School, 17, Horseferry Road, Westminster, S.W.I, the subject being " Some social aspects of Industrial Dermatitis." The King has approved the appointment of Mr. G. C. North, M.C., a Principal Assistant Secretary in the Ministry of Health, to be Registrar-General as from September 30th, 1945. Sir Sytvanus P. Vivian, the retiring Registrar-General, has held the post since 1921. In 1913 he was Assistant Secretary to the National Health Insurance Commission. Mr. G. C. North, who now succeeds him, joined the Ministry of Health in 1921 and has had wide experience of health and housing administration, including international health matters. He was a member of the British Delegation to the League of Nations Assembly in 1930, and worked with the International Health Office in Paris. The Minister of Health has appointed Major Donald Bruce, M.P., to be his Parliamentary Private Secretary. The London sessional meeting of the Royal Sanitary Institute will be held at 90, Buckingham Palace Road, London, S.W.1, on October 17th, at 2.30 p.m. Lieut.-Col. M. H. Webster, R.A.M.e., will speak on uses of D.D.T. in the field. A sound film will illustrate the lecture.
THE FUTURE
O F T H E M A T E R N I T Y AND C H I L D WELFARE OFFICER* By JEAN MACKINTOSH. M.D., D.P.H.,
Public Health Department, Birmingham There are those who say that the maternity and child welfare officer has no f u t u r e - - t h a t we have become an anachronism which must be done away with when the new National Health Service comes into force. They would maintain that the wheel has now turned full circle and that in the new health service our work, which is intimately concerned with the family unit, will be undertaken by the general practitioner as part of the ordinary service he will render to his patients. There are others, among them at least one distinguished paediatrician, who say there is no need for a medical officer to be present at a child welfare clinic, and that all the work can be done quite well by a health visitor. Only when the child shows signs of illness or failure to thrive need the doctor be consulted. Positive health is apparently a phrase which has no meaning. One can only hope that, if the recently published proposals of the Society of Medical Officers of Health for a basic training in public health are accepted, these people, including such paediatricians as think on these lines, will be among the first to take the course. When we turn to the Government's proposals for a National Health Service, we do not receive much enlightenment, although a paragraph has been devoted to the service, with 28 lines of print as compared with 13 lines to the school medical service and eight for the Medical Officer of Health, who is not even accorded the dignity of a paragraph to himself. It is interesting to note, however, that, while it is stated that when the new health service is able to take over the comprehensive care of the child's health a large part of the present duties of the school medical service will disappear, no such remarks are made about the Maternity and Child Welfare Services. It is easy to talk glibly of the maintenance of the family unit in the National Health Service, b u t it is not so simple to put it into practice and at the same time maintain, let alone improve, the efficiency of the type of service already provided. Indeed, the planners seem to be obsessed with the idea of having everything in neat and watertight compartments so that there shall be no overlap, no dual control. A rigid dividing line is to be drawn between different branches of medicine, and woe betide the practitioner who overlaps the bounds of his specialty and professes to know a little something about something else. All except the general practitioner, of course, who is to be allowed to know something about most things. I n time, we shall find this line of approach untenable and shall have to invoke the spirit of compromise. M. & C.W. Duties
During the 25 years since the last war our service has grown out of all recognition. Moreover, it is unique in the personal health services of the local authority in the extent to which hundreds of thousands of mothers and children are" brought at frequent intervals into intimate contact with medical officers and health visitors. Recent enquiry among 2,000 young women in the Services and the factories as to what in their view were women's needs in future housing revealed that they placed first among the amenities the provision of maternity and daild welfare centres. T h e main duties of the maternity and child welfare offÉcer are advisory, preventive, and educational. These duties can be carried out efficiently only in surroundings and in an atmosphere which will give the mother confidence that the doctors and nurses are prepared, and have time, to listen to her story. M. & C.W. and the G.P. Can these conditions be attained in general practice, even if based on a health centre ? Unless the habit of mind of the average general practitioner alters very much from what it is at present, these requirements would not be met in any ordinary practice and would take some time to achieve in a health centre. General practitioners have told me from time e A presidential address to the Maternity and Child Welfare Group of the Society of Medical Officers of Health.
The Trend of Diphtheria Mortality from diphtheria has fallen steadily since the great outbreak in" the last years of the 19th century. T h e deathrates per million children at ages under 15 years fell from 888 in 1901 to 310 in 1938. While this was a substantial improvement, it was nevertheless disappointing in view of the fact that, of the infectious diseases of childhood, diphtheria was the one in which the facts of aetiology was first obtained and knowledge was most complete. I n the immediate prewar years about 3,000 children died annually from this disease. At ages five to ten deaths from diphtheria exceeded in number that from the next two most important causes of death combined. T h e experience of some American and Canadian cities, over 20 years, showed a drastic reduction in mortality after the introduction of active immunisation, and led the Government in 1940 to offer a proved prophylactic free to all local authorities. Previous to this, immunisation h a d been carried out by only a few local auth6rities. T h e campaign for mass-immunisation met with varying success within the country. In some areas almost the whole of the child population had been inoculated by 1942, but for the country as a whole the proportion was not quite one-half. At one period there was a danger that even this proportion would not be maintained, but a further campaign was launched with the object of raising the percentage of immunised children to at least 75. During the last two years the drop in notifications shows that material progress is being made in the reduction of the incidence of this disease. T h e annual numbers of cases of diphtheria notified in England and Wales for 1937-44 were 61,870, 65,720, 47,910, 46,683, 51,091, 42,318, 35,944, 29,446. Judged from these figures the incidence is now approximately half the pre-war level, but it is probable that the reduction is actually greater than this, as there is evidence that the diagnostic error has risen during recent years, due to a greater readiness to send suspected cases to hospital. Until June of last year no correction was made in the returns for the error caused by including these suspected cases, which, after observation in an isolation hospital, were diagnosed differently. Mortality from diphtheria has decreased at a greater rate than the incidence : the annual deaths during 1940-43 were 2,481, 2,641, 1,827, and 1,371. T h e notifications in 1943 were threequarters of those in 1941, while the deaths were halved during this period; or, expressing the deaths as a ratio per 1,000 notifications, the proportions were 53, 52, 43, and 38 during 1940-43. T h e decrease in the ratio of deaths to notifications is influenced by the differential death-rate experienced by the non-immunised and immunised children. T h e returns of
local authorities during the first half of last year showed that 2,243 cases of diphtheria with 16 deaths occurred among the immunised children, and 6,743 cases and 368 deaths among the non-protected children. These figures give the chance of a diphtheria patient's dying as eight times greater among the non-immunised than among the immunised. If. the difference in the liability of the two groups of children to contract diphtheria is taken into account, then the chance of dying from diphtheria is at least 25 times greater among the non-immunised than among the immunised group. T h e notifications of diphtheria during the present year have again improved, and at present are only three-quarters of those for the corresponding period of 1944. T h e seasonal rise in incidence during the winter months, which has been a feature of diphtheria, was not maintained in the first weeks of this year. The result of this change in the trend was that the notifications during the first 12 weeks of this year were less than the number reported during the 12 weeks of last summer, when diphtheria was at the lowest level ever recorded until t h e n : lower weekly totals than last year's m i n i m u m have been recorded this summer. Considerable differences existed in the geographical distribution of diphtheria in the pre-war years. It was highest in the northern region and lowest in the eastern and southwestern regions. The geographical differences have shown a relative increase, because the recent decline in incidence has not been uniform throughout the country; the north has lagged behind, and now has a relatively higher proportion of the total cases than a few years ago. I n 1940 the combined counties of Cheshire, Lancashire, Yorkshire, Durham, Northumberland, Cumberland, and Westmoriand contributed 40% o f the total notifications, while in 1944 the percentage was 54. This section of the country and Wales were the only areas in which relatively large local outbreaks of diphtheria have been recorded in recent months. T h e largest of these outbreaks were in Caernarvonshire, Bangor M.B., where the notifications rose from four to 55 in one week, and in Yorkshire, Vehitley R.D., with an outbreak involving 24 persons in one week. T h e north differs from the south in type of infection, the available data suggesting that gravis infections are more common in the former. Although the prevalent type of diphtheria varies between adjacent areas and from one season to another, the distribution for the whole country has remained remarkably constant during the past four years ; the gravis type constitutes about one-half of the total, and intermedius is slightly more frequent than mitis. T h e changing distribution of age of attack was a feature of the pre-war experience : the shift was from pre-school to school ages. Official statistics do not permit of a comparison of notifications by age before June, 1944, so that the effects of immunisation on age distribution cannot yet be determined ; but the reports of Medical Officers of Health suggest that the age of attack has increased and adolescents and adults form a much larger proportion of the cases than in the prewar years. T h e success obtained by the immunisation campaign in depressing the incidence of diphtheria to the lowest level ever recorded should give encouragement for further efforts, Unless the proportion of young children immunised is maintained a few years births will yield a child population in which the immunised are in a minority. A n n u a l Luncheon Many members and a large number of distinguished guests had the opportunity at the first peace-time annual luncheon of the Society of making the acquaintance~ of the new Minister of Health, Mr. Aneurin Bevan, who, although he expressed a wish not to have his speech reported, made no observations about the new G o v e r n m e n t ' s plafts for a National Health Service. He was listened to with appreciation punctuated by applause, and it was obvious that he quickly and easily captured the good will of those who were present. T h e only other speech was that of the President of the Society, Prof. R. M. F. Picken, who proposed the toast of the guests. Among those he welcomed were Mr. C. W. Key, M.P.
PUBLIC HEALTH, October, t945 (Parliamentary Secretary to the Ministry of Health), Sir John Maude (Secretary of the Ministry of Health), Sir George Martin (Association of Municipal Corporations), Mr. W. L. Dacey (County Councils Association), Mr. E. P. Everest (Rural District Councils Association), Mr. D. M. Watson (the Royal Sanitary Institute), and Alderman W. E. Mullen (Mayor of Holbom). Mr. D. J. Jones (Urban District councils Association) was unfortunately prevented from being present. T h e President then extended a welcome to his medical colleagues, including the Presidents of the Royal Colleges, the President, Chairman, and Secretary of the British Medical Association, the President of the General Medical Council, and the Editors of the Lancet, British Medical Journal, and Medical O.fflcer. Prof. Picken spoke of the origins of the public health service and the Society nearly a hundred years ago, and the increasing part taken by its members in promoting the health of the people. He acknowledged, however, that 'the other branches of the medical profession had helped greatly to create the atmosphere necessary for public health progress. I n its views as to the future of medicine, the Society was largely in accord with the rest of the profession except that it believed that local authorities must continue to play an important part in administration. When the form of any new medical service was under consideration, it might prove worth while for the planners to study both the attractions and the repulsions to those engaged in the type of service represented by the Society. Prof. Picken assured the Minister of the support of the Society in accomplishing the great tasks which lay ahead of him. The Northern Ireland Minister of Health and Local Government has appointed a l~ental Health Services Committee under the Chairmanship of Lieut.-CoL A. R. G. Gordon, D.S.O., D.L., M.P., to advise on questions of a specialised nature in connection with mental health services. The Committee is representative of mental health services throughout Northern Ireland and will work in close co-operation with the Health Advisory Council. Any recommendations made by the Committee will be considered by the Council in the first instance, so that they can be fitted into the general plan now being worked out for Health Services of Northern Ireland as a whole. In particular, the Committee will be asked to give its views on the steps to be taken to make provision for the care and supervision of mental defectives, especially children. The Chadwick Trustees have arranged the following public lectures, admission free. On Tuesday, October 30th, at 2.30 p.m., in the Livingstone Hall of the London Missionary Society, 42, Broadway, Westminster, London, S.W.1 (opposite St. James's Park Station), Dr. W. P. Kennedy will speak on health education. On Tuesday, November 13th, at 2.30 p.m., at the Royal Sanitary Institute, 90, Buckingham Palace Road, London, S.W.1, Mr. F. C. Vokes, engineer to the Birmingham Tame and Pea District Draining Board, will deliver the Bossom Gift Lecture on the modern system of sewage disposal. The Malcolm Morris Memorial Lecture will be g~ven by Mr. Archibald M. H. Gray on Thursday, November 29th, at 2.30 p.m., in the Sir Edward Meyerstein Lecture Theatre, Westminster Hospital Medical School, 17, Horseferry Road, Westminster, S.W.I, the subject being " Some social aspects of Industrial Dermatitis." The King has approved the appointment of Mr. G. C. North, M.C., a Principal Assistant Secretary in the Ministry of Health, to be Registrar-General as from September 30th, 1945. Sir Sytvanus P. Vivian, the retiring Registrar-General, has held the post since 1921. In 1913 he was Assistant Secretary to the National Health Insurance Commission. Mr. G. C. North, who now succeeds him, joined the Ministry of Health in 1921 and has had wide experience of health and housing administration, including international health matters. He was a member of the British Delegation to the League of Nations Assembly in 1930, and worked with the International Health Office in Paris. The Minister of Health has appointed Major Donald Bruce, M.P., to be his Parliamentary Private Secretary. The London sessional meeting of the Royal Sanitary Institute will be held at 90, Buckingham Palace Road, London, S.W.1, on October 17th, at 2.30 p.m. Lieut.-Col. M. H. Webster, R.A.M.e., will speak on uses of D.D.T. in the field. A sound film will illustrate the lecture.
THE FUTURE
O F T H E M A T E R N I T Y AND C H I L D WELFARE OFFICER* By JEAN MACKINTOSH. M.D., D.P.H.,
Public Health Department, Birmingham There are those who say that the maternity and child welfare officer has no f u t u r e - - t h a t we have become an anachronism which must be done away with when the new National Health Service comes into force. They would maintain that the wheel has now turned full circle and that in the new health service our work, which is intimately concerned with the family unit, will be undertaken by the general practitioner as part of the ordinary service he will render to his patients. There are others, among them at least one distinguished paediatrician, who say there is no need for a medical officer to be present at a child welfare clinic, and that all the work can be done quite well by a health visitor. Only when the child shows signs of illness or failure to thrive need the doctor be consulted. Positive health is apparently a phrase which has no meaning. One can only hope that, if the recently published proposals of the Society of Medical Officers of Health for a basic training in public health are accepted, these people, including such paediatricians as think on these lines, will be among the first to take the course. When we turn to the Government's proposals for a National Health Service, we do not receive much enlightenment, although a paragraph has been devoted to the service, with 28 lines of print as compared with 13 lines to the school medical service and eight for the Medical Officer of Health, who is not even accorded the dignity of a paragraph to himself. It is interesting to note, however, that, while it is stated that when the new health service is able to take over the comprehensive care of the child's health a large part of the present duties of the school medical service will disappear, no such remarks are made about the Maternity and Child Welfare Services. It is easy to talk glibly of the maintenance of the family unit in the National Health Service, b u t it is not so simple to put it into practice and at the same time maintain, let alone improve, the efficiency of the type of service already provided. Indeed, the planners seem to be obsessed with the idea of having everything in neat and watertight compartments so that there shall be no overlap, no dual control. A rigid dividing line is to be drawn between different branches of medicine, and woe betide the practitioner who overlaps the bounds of his specialty and professes to know a little something about something else. All except the general practitioner, of course, who is to be allowed to know something about most things. I n time, we shall find this line of approach untenable and shall have to invoke the spirit of compromise. M. & C.W. Duties
During the 25 years since the last war our service has grown out of all recognition. Moreover, it is unique in the personal health services of the local authority in the extent to which hundreds of thousands of mothers and children are" brought at frequent intervals into intimate contact with medical officers and health visitors. Recent enquiry among 2,000 young women in the Services and the factories as to what in their view were women's needs in future housing revealed that they placed first among the amenities the provision of maternity and daild welfare centres. T h e main duties of the maternity and child welfare offÉcer are advisory, preventive, and educational. These duties can be carried out efficiently only in surroundings and in an atmosphere which will give the mother confidence that the doctors and nurses are prepared, and have time, to listen to her story. M. & C.W. and the G.P. Can these conditions be attained in general practice, even if based on a health centre ? Unless the habit of mind of the average general practitioner alters very much from what it is at present, these requirements would not be met in any ordinary practice and would take some time to achieve in a health centre. General practitioners have told me from time e A presidential address to the Maternity and Child Welfare Group of the Society of Medical Officers of Health.