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The general death-rate
174 e m p l o y m e n t of mass radiography are the factors responsible for the mortality changes in different male age groups. But why, then, have similar trends not been observed in the u p p e r age groups of the female population ? D r . Stocks suggests " that the m e n who are n o w aged 55 to 80 bore the b r u n t o f the first world war, and at the same t i m e lost a considerable fraction of their fittest m e m b e r s ; in the second world war m a n y of the same m e n were again subjected to heavy s t r ~ n s of another k i n d . " In t h e battle against disease victory is achieved not merely by forging new and m o r e p o t e n t weapons of offence, but by sound generalship and tactics which m u s t constantly be varied to m e e t the needs of a changing front. O u r entire campaign against tuberculosis has been concentrated on the h i g h mortality rates a m o n g children, adolescents and y o u n g adults. Collapse therapy, streptomycin, B.C.G., the reservation of a high p r o portion of institutional bed a c c o m m o d a t i o n for these age groups have been our considered policy. T o - d a y it is clear that increasing emphasis m u s t be placed on the males over 50 years, i.e., the older m e m b e r s of the c o m m u n i t y for w h o m little, if any, sanatorium a c c o m m o d a t i o n has b e e n m a d e available in the past. T h i s is the vulnerable spot in our defences. O u r intelligence corps has m a p p e d o u t the e n e m y dispositions. It is for us to deploy o u r forces scientifically to m e e t this n e w attack b y one of m a n k i n d ' s greatest killers.
The G e n e r a l D e a t h - r a t e T h e Monthly Supplement to the Weekly Epidemiological Record of W . H . O . for D e c e m b e r , 1948, Vol I, 19, is devoted to a dissertation on the falling general death-rate of the countries long within the registration area. W i t h the two exceptions of Eire and R o u m a n i a , the decline in the death-rate which had been in evidence before the war, was r e s u m e d after the war, so in m o s t countries the death-rates in 1946-48 have been the lowest ever recorded. T h e falls are most m a r k e d in those countries which previously had high rates, but n o t confined to t h e m ; even those cour~tries, such as Scandinavia, in which the rates have always b e e n low and seemed almost to have touched bottom, show that the real mortality rate has fallen and is continuing to fall. As death is a certainty, the fall of the death-rate m u s t m e a n an increase in the average age at death. I n the past, m o s t deaths were due either to " old age " or to infection and starvation. Age is unalterable b u t the rapidity of ageing can be slowed and something has been done in this direction, for the death-rates of those in the last age periods have fallen slightly. Starvation diseases have almost disappeared f r o m civilised countries, entirely due to h u m a n activities. Pestilences and infections have also been reduced to an extent which our forefathers w o u l d not have believed possible, but, though m u c h of this is due to our own efforts, it cannot be wholly so, even if possibly we could claim m o r e than we can prove. I n the first quarter of 1947 there was a brisk rise in mortality due to epidemic influenza. T h i s was m a d e good by the low mortality of the other three quarters, giving that year the lowest annual death-rate so far recorded. But we cannot say w h y the prevalence of influenza in 1947 did n o t equal that of 1918, n o r w h y the disease was absent in e p i d e m i c f o r m in 1948. T h e epidemic of poliomyelitis gave us no warning, nor did anybody nor could anybody foresee it. O n the other hand, the epidemic of cerebrospinal fever which started in 1939 gave warning and was foreseen, b u t we could not prevent it. W e are by no means unhopeful that we shall learn how to foresee the advent of pestilences and discover means to suppress them. W e m a y find means to suppress, or at least to delay, the onset of those diseases w h i c h destroy the aged before their allotted span is completed. Possibly we have already done so to some extent, n o t e or less as a sideline in i m p r o v i n g the health of infants and children. I f anyone avers that tonsillectomy in childhood diminishes the risk of enlarged prostate 50 years later, n o b o d y can contradict h i m ; nor could he w h o maintains the reverse be overthrown. W e have b u t a hazy notion of the remote results of our medical attentions, yet the faUing death-rate surely suggests that on the whole t h e y have been remotely beneficial. I n the early days o f child welfare m a n y h e l d that the reduction of infant mortality
PUBLIC HEALTH, June, 19't9 would cause the survival o f unfit citizens who, presumably, would have a short life and consequently a high death-rate in m i d d l e age and beyond. W e can refute this so far as middle age is concerned, for t h e infants saved in the first drive have now passed middle age ; b u t we cannot say yet how t h e y will do in the last decades of potential life. N o b o d y in these days would use the crude death-rate as evidence of the health of populations, b u t f r o m the crude rate we can calculate true mortality rates and these are falling quite substantially.
The P r e s i d e n t - E l e c t W e congratulate, on behalf of all members of the Society, Dr. H. C. M a u r i c e Williams, O.B.E., Medical Officer of Health and P o r t M e d i c a l Officer, Southampton, on his election b y the last O r d i n a r y M e e t i n g as President of the Society for the session 1949-50. C o n f e r m e n t of this office is the highest c o m p l i m e n t which our m e m b e r s can pay to one of themselves, and it has c o m m o n l y b e e n accorded to m e n w h o have shown themselves above all good and active m e m b e r s of the Society. Dr. Williams is no exception to this precedent for he has, during a large part of his m e m b e r s h i p , given m u c h unpaid time and effort to the Society's affairs, particularly as H o n o r a r y Secretary and representative on the Council of the S o u t h e r n Branch. O t h e r closely related bodies in which he has played, and still plays, an active part are the Royal Sanitary Institute, the Central Council for H e a l t h Education and the Association of Sea and Air P a r t H e a l t h Authorities, of which he is H o n o r a r y Secretary. A n o t h e r pleasing feature of this year's choice of President is that the n o m i n a t i o n came in the first instance f r o m the S o u t h e r n Branch, whose last holder of the presidency of the Society was Dr. R. A. L y s t e r in 1924-25. Lastly, D r . Williams will be the second distinguished W e l s h m a n in succession to hold this office, following as he does Prof. Parry, of Bristol. W e wish him a h a p p y and successful year. The Annual Dinner M e m b e r s are asked to n o t e that the luncheon, previously announced for S e p t e m b e r , is cancelled, and that a return is being m a d e to a D i n n e r to be held at a date not yet fixed in N o v e m b e r . Full details will appear in our next issue. G e n e r a l Practitioners and the P u b l i c H e a l t h S e r v i c e s (An extract from " Letter from Great Britain," by Dr. C. Fraser Brockington, in the Canadian ffowrnal of Public Health (April, 1949), 40, 170) " In the past there has been antagonism in England between general practitioners and local authorities, and the work of the local authority often seemed to the general practitioner to encroach upon his own work. I am convinced that this was never more than a little true, but henceforth there need be no more misunderstanding and only the rivalry of two partners striving for a common end ; the local authority and the general practitioner have been placed by the National Health Service Act in harness together. T h e school health service, the infant welfare and ante-natal clinic, the midwifery, home nursing, health visiting, home help services, and all else that the local health authority is responsible for, must now be seen in correct perspective as an aid to the general practitioner. T h e general practitioner of the future will be the family doctor perhaps more completely than ever before; all services of the local authority, whether in the clinic or the school or the home, must be regarded as accessories to his general care provided to meet some special need. ]~very woman can now book a doctor for her confinement and the ante-natal clinic assumes a new importance, as a place where continuous routine supervision and education can be conducted ; were this not so the general practitioner must inevitably be overwhelmed with additional work, since the continuous teaching of pregnant women on how to live, how best to organise their lives during gestation and the puerperium, and regular supervision against mishaps in labour, is a lengthy task. And in the truest sense so should the hospital be regarded as an accessory to the general practitioner, a place at which those of his patients can be cared for who cannot be nursed at home. Particularly should it be one of the first concerns of the regional hospital hoards to see that the work of the general practitioner is not allowed to be entirely dissociated from that of the hospitals ; the present emphasis on specialism, which is abolishing the traditional staffing of hospitals by general practitioners of the area, must be carefully balanced by an equal concern to find for him a new relationship of equivalent status."
The G e n e r a l D e a t h - r a t e T h e Monthly Supplement to the Weekly Epidemiological Record of W . H . O . for D e c e m b e r , 1948, Vol I, 19, is devoted to a dissertation on the falling general death-rate of the countries long within the registration area. W i t h the two exceptions of Eire and R o u m a n i a , the decline in the death-rate which had been in evidence before the war, was r e s u m e d after the war, so in m o s t countries the death-rates in 1946-48 have been the lowest ever recorded. T h e falls are most m a r k e d in those countries which previously had high rates, but n o t confined to t h e m ; even those cour~tries, such as Scandinavia, in which the rates have always b e e n low and seemed almost to have touched bottom, show that the real mortality rate has fallen and is continuing to fall. As death is a certainty, the fall of the death-rate m u s t m e a n an increase in the average age at death. I n the past, m o s t deaths were due either to " old age " or to infection and starvation. Age is unalterable b u t the rapidity of ageing can be slowed and something has been done in this direction, for the death-rates of those in the last age periods have fallen slightly. Starvation diseases have almost disappeared f r o m civilised countries, entirely due to h u m a n activities. Pestilences and infections have also been reduced to an extent which our forefathers w o u l d not have believed possible, but, though m u c h of this is due to our own efforts, it cannot be wholly so, even if possibly we could claim m o r e than we can prove. I n the first quarter of 1947 there was a brisk rise in mortality due to epidemic influenza. T h i s was m a d e good by the low mortality of the other three quarters, giving that year the lowest annual death-rate so far recorded. But we cannot say w h y the prevalence of influenza in 1947 did n o t equal that of 1918, n o r w h y the disease was absent in e p i d e m i c f o r m in 1948. T h e epidemic of poliomyelitis gave us no warning, nor did anybody nor could anybody foresee it. O n the other hand, the epidemic of cerebrospinal fever which started in 1939 gave warning and was foreseen, b u t we could not prevent it. W e are by no means unhopeful that we shall learn how to foresee the advent of pestilences and discover means to suppress them. W e m a y find means to suppress, or at least to delay, the onset of those diseases w h i c h destroy the aged before their allotted span is completed. Possibly we have already done so to some extent, n o t e or less as a sideline in i m p r o v i n g the health of infants and children. I f anyone avers that tonsillectomy in childhood diminishes the risk of enlarged prostate 50 years later, n o b o d y can contradict h i m ; nor could he w h o maintains the reverse be overthrown. W e have b u t a hazy notion of the remote results of our medical attentions, yet the faUing death-rate surely suggests that on the whole t h e y have been remotely beneficial. I n the early days o f child welfare m a n y h e l d that the reduction of infant mortality
PUBLIC HEALTH, June, 19't9 would cause the survival o f unfit citizens who, presumably, would have a short life and consequently a high death-rate in m i d d l e age and beyond. W e can refute this so far as middle age is concerned, for t h e infants saved in the first drive have now passed middle age ; b u t we cannot say yet how t h e y will do in the last decades of potential life. N o b o d y in these days would use the crude death-rate as evidence of the health of populations, b u t f r o m the crude rate we can calculate true mortality rates and these are falling quite substantially.
The P r e s i d e n t - E l e c t W e congratulate, on behalf of all members of the Society, Dr. H. C. M a u r i c e Williams, O.B.E., Medical Officer of Health and P o r t M e d i c a l Officer, Southampton, on his election b y the last O r d i n a r y M e e t i n g as President of the Society for the session 1949-50. C o n f e r m e n t of this office is the highest c o m p l i m e n t which our m e m b e r s can pay to one of themselves, and it has c o m m o n l y b e e n accorded to m e n w h o have shown themselves above all good and active m e m b e r s of the Society. Dr. Williams is no exception to this precedent for he has, during a large part of his m e m b e r s h i p , given m u c h unpaid time and effort to the Society's affairs, particularly as H o n o r a r y Secretary and representative on the Council of the S o u t h e r n Branch. O t h e r closely related bodies in which he has played, and still plays, an active part are the Royal Sanitary Institute, the Central Council for H e a l t h Education and the Association of Sea and Air P a r t H e a l t h Authorities, of which he is H o n o r a r y Secretary. A n o t h e r pleasing feature of this year's choice of President is that the n o m i n a t i o n came in the first instance f r o m the S o u t h e r n Branch, whose last holder of the presidency of the Society was Dr. R. A. L y s t e r in 1924-25. Lastly, D r . Williams will be the second distinguished W e l s h m a n in succession to hold this office, following as he does Prof. Parry, of Bristol. W e wish him a h a p p y and successful year. The Annual Dinner M e m b e r s are asked to n o t e that the luncheon, previously announced for S e p t e m b e r , is cancelled, and that a return is being m a d e to a D i n n e r to be held at a date not yet fixed in N o v e m b e r . Full details will appear in our next issue. G e n e r a l Practitioners and the P u b l i c H e a l t h S e r v i c e s (An extract from " Letter from Great Britain," by Dr. C. Fraser Brockington, in the Canadian ffowrnal of Public Health (April, 1949), 40, 170) " In the past there has been antagonism in England between general practitioners and local authorities, and the work of the local authority often seemed to the general practitioner to encroach upon his own work. I am convinced that this was never more than a little true, but henceforth there need be no more misunderstanding and only the rivalry of two partners striving for a common end ; the local authority and the general practitioner have been placed by the National Health Service Act in harness together. T h e school health service, the infant welfare and ante-natal clinic, the midwifery, home nursing, health visiting, home help services, and all else that the local health authority is responsible for, must now be seen in correct perspective as an aid to the general practitioner. T h e general practitioner of the future will be the family doctor perhaps more completely than ever before; all services of the local authority, whether in the clinic or the school or the home, must be regarded as accessories to his general care provided to meet some special need. ]~very woman can now book a doctor for her confinement and the ante-natal clinic assumes a new importance, as a place where continuous routine supervision and education can be conducted ; were this not so the general practitioner must inevitably be overwhelmed with additional work, since the continuous teaching of pregnant women on how to live, how best to organise their lives during gestation and the puerperium, and regular supervision against mishaps in labour, is a lengthy task. And in the truest sense so should the hospital be regarded as an accessory to the general practitioner, a place at which those of his patients can be cared for who cannot be nursed at home. Particularly should it be one of the first concerns of the regional hospital hoards to see that the work of the general practitioner is not allowed to be entirely dissociated from that of the hospitals ; the present emphasis on specialism, which is abolishing the traditional staffing of hospitals by general practitioners of the area, must be carefully balanced by an equal concern to find for him a new relationship of equivalent status."