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Vital statistics during the war
PUBLIC
HEALTH
SOCIETY OF MEDICAL OFFICERS OF HEALTH No: 1
Vol. LIX
OCTOBER~ 1945 CONTENTS PAGE
EDITORIAL Vital S t a t i s t i c s D u r i n g t h e W a r . . . . . . . . . . . . . . . . . . . . . The Trend of Diphtheria . . . . . . . . . . . . . . . . . . . . .
1 2
PAGE
OBITUARY Dr.
A. H . L o w e
. . . . . . . . . . . . . . . . . . . . . . . . . . .
8
SPECIAL ARTICLES The
F u t u r e o f t h e M a t e r n i t y a n d C h i l d VCelfare Officer. By J e a n Mackintosh, Mm., n.l'.H . . . . T h e P u b l i c D e n t a l S e r v i c e . By "j~ J . Hodson','¥,D,S*); R.C.S.' (Edin'.) ,..
3 5
NEWS AND SUMMARY and Advisory Scheme
National Milk Testing
. . . . . . . . . . . .
THE SOCIETY
OFFICERS
OF HEALTH
7
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
8 8 8
School Medical Service Group Northern Branch . . . . . . . West of England Branch Branch and Group Elections
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . . . . . .
BOOK REVIEWS Psychology in G e n e r a l P r a c t i c e . . . . . . . . . . . . . . . . . . Physician Heal Thyself . . . . . . . . . . . . . . . . . . . . . Social W o r k for the T u b e r c u l o u s " .. . . . . . . . . . . . . . . . .
OF MEDICAL
C . . . . il M e e t i n g . . . . . . . . . . General Purposes Committee . . . Yorkshire Branch . . . . . . . . . . Welsh Branch . . . . . . . . . .
EDITORIAL Vital Statistics During the W a r T h e experience of the past is generally the only guide to future events, particularly when attempting to predict the trends of diseases known to be sensitive to social upheavals. At the outbreak of war certain unknown quantities--the effects of mass air attacks and of shelter life on the well-being of the community--led to doubts and fears about t h e future course of vital statistics. Perhaps more by good fortune than good judgment no catastrophe occurred. T h e trend of vital statistics during the war was similar in several respects to the experience of 1914-18, but there were some striking contrasts. I n both periods the declaration of war resulted in a large increase in the n u m b e r of marriages. In 1915 the rate rose to 19-4 and then fell to the lowest level recorded--13-8 in 1917. T h e end of the war brought another marriage boom, and rates of 19-8 and 20.2 were recorded in 1919 and 1920. The marriage-rate rose to 21.2 in 1939, increased to the record level of 22.7 in 1940, remained above the peace-time level for the two following years, and then fell to 14.3 in 1943. T h e fall in the birth-rate continued during the first years of war, the rate of 14.2 in 1941 being the lowest ever on record ; but from 1942--44 the rate rose to 15.8, 16-5 and 18.0, the last being the highest since 1925. T h e contrasting trends of the marriage and birth-rates in the two wars was due to the differing geographical distribution of the army. I n the first war most of the army was outside the country for long periods, but in the war of 1939-45 a large army was kept at home for some years. T h e general death-rate rose to 14-4 per 1,000 in 1940, 0.6 of this rate being due to civilian war deaths : it was the highest rate since 1918. T h e death-rate fell in 1941 to 12-9, and varied between 11-6 and 12.1 in 1942-44, which compared favourably with 12-0, the average of 1935-39. Infant mortality, which had fallen to 50 per 1,000 live births in 1939, rose to 56 and 59 in the two succeeding years ; but in 1942-44 the rates were 49, 49, and 46--the lowest yet experienced in this country. T h e mass evacuation-of children after the outbreak of war caused some foreboding. Many epidemiologists thought that the mingling of populations with different degrees of resistance to the common infectious diseases of childhood would cause a large increase in these complaints. Although under arrangements by the Ministry of Health and the Board of Education about three-quarters of a million children were evacuated from congested and industrialised areas, there was no large increase in notifications of infectious diseases; in fact, the expected epidemic of measles of 1939-40 was postponed. There was, however, some evidence that native country children had a somewhat heavier incidence than billeted town children. A notable advance in the control of diphtheria was made by the Government's campaign for immunisation. Notifications of diphtheria have steadil~
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . . . . . .
. . . .
. . . . . . . . .
. . . . . . . .
. . . . . . .
9 9 10 11 11 11 12 12
fallen since 1941, until in the present year they have reached a new low level. The incidence is now approximately half the pre-war level, and the mortality, judged from the experience of the great towns, has declined more than the incidence. It was suggested that the conditions of overcrowding, shelter life, black-out with lack of'ventilation, etc., particularly in London and the South, would favour an epidemic of influenza, and the memories of the pandemic of 1918 gave this possibility a real significance. Actually the annual outbreaks of influenza were comparatively light and the only occasion for anxiety was during the epidemic of 1943, when the incidence began to increase about two months earlier than usual. Over I,I00 deaths were attributed to influenza in the large towns in the 49th and also in the 50th week, this being from 20 to 30 times the normal seasonal n u m b e r ; but the epidemic waned quickly and had practically disappeared by early spring, when the usual maximum occurs. After the outbreak of war there was a large increase in cerebrospinal fever, an experience similar to that of 1914-18. The cases in the recent outbreak were widespread, While in the epidemic of 1914 they tended to be concentrated about the large military camps. During the ninth week of 1940 notifications reached a maximum of 617, this being from 12 to 20 times the preceding annual maxima. In the summer the incidence dropped to about six times the peace-time endemic level. T h e intensity of the successive annual waves of cerebrospinal fever have lessened, and in 1944 and 1945 the incidence appears to have become stabilised at two or three times the pre-1939 level. T h e discovery and adoption of treatment by sulphonamide drugs has considerably reduced }he fatality rate. I n 1915-17 there were 8,068 notifications and 5,222 deaths, yielding a fatality rate of 64"72%. In 1940-41 there were 23,840 notifications and 4,747 deaths, giving a fatality rate of 19-91%. It was anticipated that an increase in the incidence of typhoid and paratyphoid fevers, perhaps to epidemic proportions, would result from a disruption of the water and sewerage system. This danger was averted, and except in 1941 the cases of enteric fever have been fewer than in the years of peace. T h e most spectacular of the 1941 outbreaks of paratyphoid was that which began in Liverpool, Bootie, and Birkenhead in June, and which had involved 883 persons by the beginning of September. T h e Liverpool cases first occurred in a densely populated area which had suffered severely from the bombing during the earlier part of the year, and it was immediately suspected that the bombing had led to pollution of the water supply, but all the samples of water taken were above reproach. The source of infection was eventually traced to a large bakery with multiple branches. No fewer than ten excretors of Bact. paratyphosum B were found in this establishment. I n contrast to the trend of enteric fever, the incidence of dysentery has steadily risen since 1939 and is at present times the pre-war level. T h e annual notifications of
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.
HEALTH
SOCIETY OF MEDICAL OFFICERS OF HEALTH No: 1
Vol. LIX
OCTOBER~ 1945 CONTENTS PAGE
EDITORIAL Vital S t a t i s t i c s D u r i n g t h e W a r . . . . . . . . . . . . . . . . . . . . . The Trend of Diphtheria . . . . . . . . . . . . . . . . . . . . .
1 2
PAGE
OBITUARY Dr.
A. H . L o w e
. . . . . . . . . . . . . . . . . . . . . . . . . . .
8
SPECIAL ARTICLES The
F u t u r e o f t h e M a t e r n i t y a n d C h i l d VCelfare Officer. By J e a n Mackintosh, Mm., n.l'.H . . . . T h e P u b l i c D e n t a l S e r v i c e . By "j~ J . Hodson','¥,D,S*); R.C.S.' (Edin'.) ,..
3 5
NEWS AND SUMMARY and Advisory Scheme
National Milk Testing
. . . . . . . . . . . .
THE SOCIETY
OFFICERS
OF HEALTH
7
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
8 8 8
School Medical Service Group Northern Branch . . . . . . . West of England Branch Branch and Group Elections
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . . . . . .
BOOK REVIEWS Psychology in G e n e r a l P r a c t i c e . . . . . . . . . . . . . . . . . . Physician Heal Thyself . . . . . . . . . . . . . . . . . . . . . Social W o r k for the T u b e r c u l o u s " .. . . . . . . . . . . . . . . . .
OF MEDICAL
C . . . . il M e e t i n g . . . . . . . . . . General Purposes Committee . . . Yorkshire Branch . . . . . . . . . . Welsh Branch . . . . . . . . . .
EDITORIAL Vital Statistics During the W a r T h e experience of the past is generally the only guide to future events, particularly when attempting to predict the trends of diseases known to be sensitive to social upheavals. At the outbreak of war certain unknown quantities--the effects of mass air attacks and of shelter life on the well-being of the community--led to doubts and fears about t h e future course of vital statistics. Perhaps more by good fortune than good judgment no catastrophe occurred. T h e trend of vital statistics during the war was similar in several respects to the experience of 1914-18, but there were some striking contrasts. I n both periods the declaration of war resulted in a large increase in the n u m b e r of marriages. In 1915 the rate rose to 19-4 and then fell to the lowest level recorded--13-8 in 1917. T h e end of the war brought another marriage boom, and rates of 19-8 and 20.2 were recorded in 1919 and 1920. The marriage-rate rose to 21.2 in 1939, increased to the record level of 22.7 in 1940, remained above the peace-time level for the two following years, and then fell to 14.3 in 1943. T h e fall in the birth-rate continued during the first years of war, the rate of 14.2 in 1941 being the lowest ever on record ; but from 1942--44 the rate rose to 15.8, 16-5 and 18.0, the last being the highest since 1925. T h e contrasting trends of the marriage and birth-rates in the two wars was due to the differing geographical distribution of the army. I n the first war most of the army was outside the country for long periods, but in the war of 1939-45 a large army was kept at home for some years. T h e general death-rate rose to 14-4 per 1,000 in 1940, 0.6 of this rate being due to civilian war deaths : it was the highest rate since 1918. T h e death-rate fell in 1941 to 12-9, and varied between 11-6 and 12.1 in 1942-44, which compared favourably with 12-0, the average of 1935-39. Infant mortality, which had fallen to 50 per 1,000 live births in 1939, rose to 56 and 59 in the two succeeding years ; but in 1942-44 the rates were 49, 49, and 46--the lowest yet experienced in this country. T h e mass evacuation-of children after the outbreak of war caused some foreboding. Many epidemiologists thought that the mingling of populations with different degrees of resistance to the common infectious diseases of childhood would cause a large increase in these complaints. Although under arrangements by the Ministry of Health and the Board of Education about three-quarters of a million children were evacuated from congested and industrialised areas, there was no large increase in notifications of infectious diseases; in fact, the expected epidemic of measles of 1939-40 was postponed. There was, however, some evidence that native country children had a somewhat heavier incidence than billeted town children. A notable advance in the control of diphtheria was made by the Government's campaign for immunisation. Notifications of diphtheria have steadil~
. . . .
. . . .
. . . .
. . . .
. . . .
. . . .
. . . . . . . .
. . . .
. . . . . . . . .
. . . . . . . .
. . . . . . .
9 9 10 11 11 11 12 12
fallen since 1941, until in the present year they have reached a new low level. The incidence is now approximately half the pre-war level, and the mortality, judged from the experience of the great towns, has declined more than the incidence. It was suggested that the conditions of overcrowding, shelter life, black-out with lack of'ventilation, etc., particularly in London and the South, would favour an epidemic of influenza, and the memories of the pandemic of 1918 gave this possibility a real significance. Actually the annual outbreaks of influenza were comparatively light and the only occasion for anxiety was during the epidemic of 1943, when the incidence began to increase about two months earlier than usual. Over I,I00 deaths were attributed to influenza in the large towns in the 49th and also in the 50th week, this being from 20 to 30 times the normal seasonal n u m b e r ; but the epidemic waned quickly and had practically disappeared by early spring, when the usual maximum occurs. After the outbreak of war there was a large increase in cerebrospinal fever, an experience similar to that of 1914-18. The cases in the recent outbreak were widespread, While in the epidemic of 1914 they tended to be concentrated about the large military camps. During the ninth week of 1940 notifications reached a maximum of 617, this being from 12 to 20 times the preceding annual maxima. In the summer the incidence dropped to about six times the peace-time endemic level. T h e intensity of the successive annual waves of cerebrospinal fever have lessened, and in 1944 and 1945 the incidence appears to have become stabilised at two or three times the pre-1939 level. T h e discovery and adoption of treatment by sulphonamide drugs has considerably reduced }he fatality rate. I n 1915-17 there were 8,068 notifications and 5,222 deaths, yielding a fatality rate of 64"72%. In 1940-41 there were 23,840 notifications and 4,747 deaths, giving a fatality rate of 19-91%. It was anticipated that an increase in the incidence of typhoid and paratyphoid fevers, perhaps to epidemic proportions, would result from a disruption of the water and sewerage system. This danger was averted, and except in 1941 the cases of enteric fever have been fewer than in the years of peace. T h e most spectacular of the 1941 outbreaks of paratyphoid was that which began in Liverpool, Bootie, and Birkenhead in June, and which had involved 883 persons by the beginning of September. T h e Liverpool cases first occurred in a densely populated area which had suffered severely from the bombing during the earlier part of the year, and it was immediately suspected that the bombing had led to pollution of the water supply, but all the samples of water taken were above reproach. The source of infection was eventually traced to a large bakery with multiple branches. No fewer than ten excretors of Bact. paratyphosum B were found in this establishment. I n contrast to the trend of enteric fever, the incidence of dysentery has steadily risen since 1939 and is at present times the pre-war level. T h e annual notifications of
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.