616

that today notification is fairly complete for polio-myelitis, cerebrospinal fever, diphtheria, and scarletfever, but in defect by some 10% for respiratorytuberculosis, by 20% for the enteric fevers, and by30% for measles ; he estimates that of pneumoniacases only a third to a quarter, and of whooping-cough cases even less, are notified. It is thus verypossible that some of the recorded attack-rates willrise appreciably in the next few years if, under thehealth service, the doctor’s help is more freely invoked.A table of the notified cases of acute poliomyelitis

and polioencephalitis brings out the magnitude of the1947 epidemic. In 1944-46 the average rate of notifi-cations was 1-7 per 100,000 persons of all ages, whereasin 1947 it was 18-3-an elevenfold increase. This orderof increase is apparent at each age ; so the outbreakdoes not appear to have been at all selective by age.In regard to cerebrospinal fever, STOCKS estimatesthat at present rates of inception, 1 in 240 children willbe notified before reaching the age of fifteen. Thetuberculosis position will be dealt with more fully in alater report, but it is noted here that whereas duringthe inter-war years 5 out of 10 persons notified died

- subsequently of the disease, the proportion has nowfallen to 4 out of 10. It seems more likely that mildercases are now being brought into the notification figuresthan that the fatality-rate has fallen generally.

The notification statistics of the infectious diseasesare, if not exactly ancient, at least of respectableantiquity ; and they are freely used as broad measuresof epidemic events. The Social Survey of sickness,on the other hand, is a recent experiment whichmust be-as our American friends would say-" validated." Informants are asked about illness inthe two previous months ; and the statistics reveal,as would be expected, difficulties in recalling the datewhen an illness began. It appears that this failure of

memory tends to bring into the period illnesses whichin fact began outside it-an error that will to someunknown extent compensate for illnesses that havebeen forgotten altogether. Another difficulty is in

deciding whether people’s own accounts of theirmaladies are reliable ; and here, says STOCKS, " thepatient often has to decide whether or not he is ill atall." A check of the incidence-rates produced by theseself-reported illnesses against some of those yieldedby notification of infectious diseases or through foodpermits suggested that the statements are prettyreliable ; but the check is, of course, not whollyconvincing, since the other two sources supply informa-tion only about certain diseases, usually serious andtherefore easily remembered, particularly if, while a foodallowance is being drawn, an

" official " interviewercalls to ask about illness. Whatever its shortcomings,the survey does collect much information that wouldotherwise not be gathered into the statistical net ;for of those reporting an illness, only 1 in 7 has

stayed away from work (or, in the case of a housewife,been confined to the house), and only 1 in 4 hasconsulted a doctor ; only 1 in 9 of men of workingage who say they have been indisposed have stayedaway from work for as long as four days-theminimum period that would usually bring theillness into the National Insurance statistics. It maybe asked whether this vast mass of " illness " is so

slight as hardly to justify the heavy task of recordingit. The answer will depend on whether the resultscan throw light on changes in the state of the publichealth, on whether the exponents of social medicine

can base health measures on these results, and alsoon whether epidemiology-a term which by modernusage we can extend to all disease-will be advanced.The final section, on the statistics of priority allow-

ances of foods given for certain diseases, reveals (atthe end of 1947) approximately 100,000 diabetics inEngland and Wales, or about 23 per 1000 of the

population ; 4467 cases of thyrotoxicosis (at the endof 1945) with a sex ratio of about 1 male to 3 5 females ; Tand 118,000 cases of respiratory tuberculosis receivingpriority milk, or 2-8 per 1000 persons. The figuresfor gastric and duodenal ulcer are curious. Thetotal number in England and Wales in December,1945, was roughly 342,000, and a year later it wasof the same order-339,000. By March, 1947, ithad risen to 382,000, and by December of that yearto 437,000. The explanation is perhaps a more

earnest attempt by dyspeptics to secure the priorityallowances rather than an increased prevalence.

In a brief introduction the REGISTRAR-GENERAL

promises further studies, to be devoted to tuberculosis,accidents, and migration. The object of the series,he says, is " to provide in convenient form a moreextensive treatment of important subjects than is

practicable within the limits of the Annual Review."One might add that there is also gain in not buryingthese readable studies within covers that are rarelyopened except by statisticians. With these two openingnumbers Dr. STOCKS has certainly given the series arare start.

Annotations

BRITISH MEDICAL GUILD

DURING the last three revealing years the BritishMedical Association has learned much about its own

strengths and weaknesses, when it is faced with the taskof negotiating with the Government and with other

public bodies. In particular it has found that it is

precluded by its own constitution from any activitythat might be held by a court of law to be one thatcould properly be performed only by a trade union.It was for this reason that the Independence Fund andits trustees were established ; it would have been

deputed to undertake organised opposition against theNational Health Service Act had that been the willof an effective majority of the profession. The crisiswhich then passed may not be the last that will haveto be faced, and so the representative body of the association debated last week what changes are needed toprovide machinery for representing grievances in thefuture, and for organising pressure if necessary. Three

possibilities were canvassed. The first was that of

leaving the association in its present form except forrevoking the clauses in its constitution which limit its

syndicalist activities. This would in effect turn the

present association into a limited company and wouldhave disadvantages both in nomenclature and in liabilityto taxation. The second suggestion was that the asso-ciation might be turned into a trade union (or failingthis into a friendly society). It was found that neither

change could be made easily. In law it was doubtfulif a group of doctors could successfully claim to be agroup of workmen, or of employers, and they mighttherefore not qualify for the protection given to suchspecified groups by the Trades Disputes Act. In anycase, conversion to a trade union or a friendly societycould not be undertaken without first winding up theexisting association, and distributing all its assets among

617

its present members. Therefore, after long discussion, athird course (and the one favoured all along by thecouncil) was accepted. This was to form a parallelorganisation-in appearance not unlike that of the

Independence Fund and its trustees—which will beknown as the British Medical Guild.The guild is to have no membership. It will in effect

be but a board of trustees. The trustees will consist of

any or all of the members for the time being of thecentral council of the B.M.A., who have individuallygiven their assent to serve. The guild will, when sorequired, endeavour to rouse support and organise actionin favour of the association’s policy as then current.To finance the guild’s activities, and to provide resourcesfrom which it could indemnify doctors who suffer lossor hardship through participation in collective action,there will have to be substantial funds. These fundsit is hoped will be raised within reasonable time byvoluntary subscription from the profession.Time alone will show how powerfully and successfully

such an organisation can act. Meanwhile the associationis fortified by -learned legal opinion that the proposedguild could carry out its intended functions of organisingand financing collective action by the profession, and ofproviding financial compensation to practitioners suffer-ing financial hardship through participation in suchcollective action, without in any way endangering thelife or position of the association itself.

AN EPIDEMIC OF THYROTOXICOSIS

BETWEEN 1942 and 1945 a remarkable increase inthe incidence of thyrotoxicosis was recorded in Denmark.The rise, and subsequent fall, in the number of caseswas abrupt enough to justify the use of the term"

epidemic," though without implying that any infectiousagent was concerned. The facts have been recordedwith admirable thoroughness by Iversen in a monographpublished in 1948, and now summarised elsewhere.2

Iversen’s detailed - figures relate to all cases in

Copenhagen entering hospital for the first time withthe diagnosis of thyrotoxicosis ; and he found thatthe incidence in the whole country ran parallel to thatin the capital. His figures show that there was a slowincrease in incidence from 1938 to 1941. In 1942 therewas a rapid rise, with a further slight increase untilthe peak was reached in 1944. After that there was a

sharp fall, till- in 1947 the incidence was the same as in1940. Iversen feels confident that his records includevirtually all cases of thyrotoxicosis in Copenhagen,and he is able to state actual figures for the incidenceof the disease. Thus, in 1938 there were 0-19 cases

per 1000 inhabitants ; in 1944, 0-83 ; in 1947, 0-21.The chances of an inhabitant of Copenhagen developingthyrotoxicosis were about four times as great at the

height of the epidemic as before or since.The increase was, he believes, real, and not simply

the result of better diagnosis. It cannot have beendue simply to the psychological effects of the Germanoccupation, for it started during 1941, when the behaviourof the invaders was comparatively mild, and it showedonly a slight further rise in 1944, when the Germans"got tough." Moreover, during the same period theincidence and severity of thyrotoxicosis in Belgiumtended, if anything, to decrease.3 In Holland alsothere seems to have been a fall,4 while in Norway asmall increase in incidence in the early stages of theGerman occupation was followed by a fall.5Two other factors may have played some part-weather

and diet. Iversen points out that the winters of 1940,1. Iversen, K. Temporary Rise in the Frequency of Thyrotoxicosis

in Denmark, 1941-45. Copenhagen, 1948.2. Iversen, K. Amer. J. med. Sci. -1949, 217, 121.3. Bastenie, P. A. Lancet, 1947, i, 789.4. Schweitzer, P. M. J. Acta. med. scand. 1944, 119, 306.5. Grelland, R. Ibid, 1946, 125, 108.

1941, and 1942 were unusually severe, and there is

experimental evidence that exposure to cold stimulatesthe thyroid. It is not perhaps very likely that thehard winter of 1942 would still be causing fresh casesof thyrotoxicosis in 1944, but this possibility cannot beexcluded, since Iversen’s cases are grouped by the date,not of onset, but of entry into hospital. During theGerman occupation the diet of the Danish people variedcomparatively little, and was never grossly deficient asin Belgium and Holland. Iversen’s suggestion in thisconnexion is ingenious, if rather far-fetched. Before thewar large quantities of soya-bean oil were imported ascattle-feed ; these imports ceased in 1941. Soya beanis well known to contain an antithyroid factor, andthis factor might be contained in the cattle-feed andsubsequently in the cow’s milk (though this has neverbeen proved) ; cutting off the supply of this factormight unleash a series of fresh cases.

If we review the events in Belgium, Holland, Norway,and Denmark as a whole, the least unacceptable theoryseems to be that the invasion of these countries by theGermans did increase the tendency of the inhabitantsto develop thyrotoxicosis, but that this tendency wasmasked in the case of Belgium and Holland by thehighly abnormal diet. The masking effect of the dietmight be due to lack of calories or of protein, or to excessof vegetables containing antithyroid factors. This theorygets its chief support from the experience of Norway.There the diet remained adequate during the first year orso of the German occupation but became deficientlater; and an initial increase in thyrotoxicosis wasfollowed by a decrease at about the time when thediet deteriorated. It. is tempting to suppose that .theincrease was caused by the psychological effects ofinvasion, and the decrease by the poor diet ; but thereis no certain proof.

TRANSMISSION OF LIGHT THROUGH SKIN

DURING the last years of the German occupation and" in the course of evening hours," Dr. Hansen 1 investi-’gated the transmission of light through the skin. After

preliminary experiments he chose to work with a ‘

Philips super high-pressure mercury arc-lamp (capable,of emitting a constant supply of ultraviolet rays giving" a quasi-continuous spectrum ") and a photo-electriccell for estimating the intensity of the transmitted light.He compared transmission through skin excised fromthe mouse immediately after death or during anaesthesia,skin stored in an ice-chest, skin from pedicle grafts,skin obtained at necropsy, and skin removed at operationor after blistering. He found that all except the storedskin gave almost identical and constant curves. Trans-mission through stored skin was greater, but the curveswere similar. He concludes that within the wave-lengths500 mµ and 300 mµ the course of the transmission curveis the same for live mouse skin, for skin excised shortlyafter death, and for frozen sections of both types ofskin, decreasing uniformly with the wave-length from500 to 300 mµ, with a minimum at 415 mµ, attributed

mainly to haemoglobin absorption. The various layersof skin are not characteristic in their absorption ofradiation, and there is nothing in the results to indicatethat there is any wave-length region to which a specificbiological effect on skin tissue can be ascribed.The only uncertainty left by these careful experiments

is whether the current from the photo-electric cell is

proportional to the intensity of the light falling on it.Hansen says he investigated this point at four wave-lengths (313-450 mµ) and found that it was proportional,but he admits that this is contrary to accepted opinionand offers the explanation that the light intensities he1. On the Transmission through Skin of Visible and Ultraviolet

Radiation. By K. G. HANSEN. Acta radiol., Stockh. 1948,suppl. 77. Pp. 106. Sw. Kr. 8.

P 4