- Email: [email protected]
Clean food
PUBLIC HEALTH.
1926. CLEAN
FOOD. ~
By CHARLES PORTER, M.D., B.Sc., M . R . C . P . , Ed., Medical Officer of Health, St. Marylebone.
My chief reason for choosing this as the subject of my Presidential address is that it gives an o p p o r t u n i t y of expressing appreciation of the efforts of a n n m b e r of colleagues in this and other Branches of the Society, and of m a k i n g use of work done and m o n o g r a p h s prepared by them in reporting progress in a matter we are all interested in and to which I personally drew attention in a paper read at the Royal S a n i t a r y I n s t i t u t e Congress at Liverpool in 1!)24. In this paper, in addition to g i v i n g my imp:ressions of American methods of food handling, 1 also expressed s t r o n g views on our own s h o r t c o m i n g s in this regard. C l a i m i n g for us, as a nation, that so far as regards table m a n n e r s we were the most precise on earth, and as eaters the cleanest and most fastidious, I had to point out that in the matter of food itself, its production and protection, we were, of the more progressive peoples, probahly the most neglectful. R e g a r d i n g this as a proposition likely to be selfevident to the members of my audience, I did not take the trouble to give much in the shape of proof. I did no more, in fact, than indulge in generalities and offer s u g g e s t i o n s as to what l t h o u g h t should be done with a view to o b t a i n i n g improvements. The chief of these s u g g e s t i o n s had relation to education and p r o p a g a n d a , which I held to be necessarv in the case of the public, the traders, and the legislature. Of the three the most i m p o r t a n t appeared to me to be the public, since if desire for information could be awakened a m o n g s t the people, very soon the need for m a k i n g and enforcing these i m p r o v e m e n t s would be recognised bv the traders and the legislature. Education of the traders I regarded as more or less a hopeless task for us to undertake. The influencing of the legislature, t h o u g h perhaps not quite so hopeless, it seemed could be done very much more effectively by the public. So far as the traders were concerned, I counselled that we should make no special effort in the n a t u r e of a direct attack, r e c o m m e n d i n g rather that we should concentrate upon the people and devote some of the time that we were g i v i n g to medical p r o p a g a n d a , to teaching facts with * Presidontial Address 1o Motropolitar., Branch, Society o f Medical Ofl~c¢'rs of l lealth, November 27th, 1925,
97
regard to food and to o p e n i n g eyes to the necessity for cleanliness in regard to it. The legislature I did not feel we could leave alone entirely. I recommended, therefore, that there should be set up a special committee jointly by the Society and the Royal S a n i t a r y Institute, whose reference should be, after considering the whole matter, to approach the Minister of Health in order to urge him to a m e n d existing legislation and to provide new laws g o v e r n i n g the preparation and sale of food, and r e q u i r i n g that all persons concerned in its production, preparation or sale shall take all precautions necessary to ensure its proper cleanliness and freedom from contamination. So far as my knowledge goes tile only one of these suggestions that has been adopted is that relating to the s e t t i n g up of a Joint Committee. Education and p r o p a g a n d a a m o n g s t the people may have been g o i n g on and, as I said in my paper, some of us may have stopped t a l k i n g about teeth and a d v i s i n g the c o n s u m p t i o n of four glasses of water per day for a season, c o n c e n t r a t i n g instead on the g i v i n g of such instruction as would lead housewives and others to attack food producers and vendors and the G o v e r n m e n t , and compel them to mend their ways. This I do not know, but I have not seen mtwh evidence of it. The recommendation as to the s e t t i n g up of the Joint Committee was not only accepted, but was acted upon. Nay, more, the Committee has done its work, has approached the Minister, and has been received, if not by himself personally, then by his Chief Medical Officer acting as his representative. It is of these things that I would now speak. The Committee appointed by ourselves and the Institute was an exceedingly representative o n e ; more than that, it was very e n t h u s i a s t i c and hardworking. T o me personally, and as your President, it is a source of gratification that no fewer than half the m e m b e r s were colleagues in the Metropolis and also M e m b e r s of this Branch. Not only so, but at the time of a p p o i n t m e n t all were or had been officers of the Branch ; three, Dr. Allan, Dr. Kenwood and Dr. W i l l o u g h b y , being past Presidents, Dr. F e n t o n , our Secretary, m a k i n g the fourth, and myself the fifth. F o r some reason or other the Committee did me the h o n o u r of a p p o i n t i n g me C h a i r m a n , and when I saw what m e m b e r s h i p of the Committee was to imply in the shape of work, and that the chair was to be practically a place of rest, I must confess that I felt rather glad that I had been put there.
98
PUBLIC HEALTH.
R e c o g n i s i n g t h a t much of the t a l k with r e g a r d to food h a n d l i n g and the neglectfulness of handlers, and the d a n g e r s a s s o c i a t e d therewith, was largely only talk and in the form of generalities, the C o m m i t t e e at its first m e e t i n g decided that the best plan to a d o p t would be to a r r a n g e for the c a r r y i n g out of as complete an investigation as possible of certain definite food trades. To this end each m e m b e r a g r e e d to t a k e up a business or an aspect of the question and to prepare a memorandum. The subjects i n v e s t i g a t e d and the m e m b e r s t a k i n g responsibility for the p r e p a r a t i o n of the m o n o g r a p h s were : - (a) Meat and M e a t P r o ducts ...... Mr. J. R. H a y h u r s t , M.R.C.V.S. Prof. H. R. Ken(b) F i s h ... wood, C . M . G . , M.B. (c) F r u i t and VegeJ. F e n t o n , M.D. tables . . . . . . (d) Bread and ConfecJ,~seph Cates, M.D. tionery . . . . . . (e) Milk, Ice Cream, Thomas Orr, M.D., etc . . . . . . . D. Sc. Sir W i l f r e d Beveridge, (f) Groceries . . . . . . K . B . E . , C.B., D . S . O . (g) R e s t a u r a n t s and F. J. Allan, M.D. Cafes . . . . . . (h) F o o d R e g u l a t i o n s , Licensing and Registration of Premises ... F. J. Allan, M.D. (i) P r e m i s e s where Prepared Food is Made ... T. \V. N a y l o r Barlow, O . B . E . , M.D. (j) I m p o r t e d F o o d s ... Yr. M. W i l l o u g h b y , M.D. The a d v a n t a g e s of such an a r r a n g e m e n t must l~e obvious and were enormous. T h e n u m b e r of inv e s t i g a t o r s who had little to do or say w a s small, most of the businesses affording an a s t o n i s h i n g a m o u n t of scope and the i n v e s t i g a t i o n s revealing the existence of a g r e a t m a n y more opportunities for contamination, and a g r e a t e r a m o u n t of uncleanliness even, than had ever been referred to in the general indictments c o m m o n l y heard. This, no doubt, was to be expected, since, in the main, the i n v e s t i g a t i o n s were p r o p e r l y planned and methodically carried out. As a model I would c o m m e n d to you the report of Dr. F e n t o n , w h o u n d e r t o o k to enquire into the t r a d e of fruit and v e g e t a b l e s . A l o n g with the
JANUARY,
o t h e r r e p o r t s this will, I hope, be published, and as you will all of you I know read it, it is unnecessary for me to discuss it at any length. The only t h i n g I desire to do, and as illust r a t i n g the point just made, with r e g a r d to method, is to point out t h a t from his report it is clear t h a t Dr. F e n t o n b e g a n his o b s e r v a t i o n of v e g e t a b l e s and fruit intended for h u m a n food consumption at the b e g i n n i n g , and followed them from the m a r k e t g a r d e n and the orchard, t h r o u g h the hands of the p i c k e r s and p a c k e r s and carriers, to the retailers and costers, and eventually to tile consumer. Of the c o n t a m i n a t i o n s to which they are liable at all s t a g e s none a p p e a r s to be overlooked, from those that m a y be picked up from the soil in which they are g r o w n , to those that may be acquired from i m p r o p e r l y t r a i n e d dogs, when the g o o d s are stacked, as is so often the case, on the streets and p a v e m e n t s outside shops and m a r k e t s . A n o t h e r r e p o r t which I am certain will appeal to all, and will be p a r t l c u l a r l y i n t e r e s t i n g and helpful to those of us whose districts are rich in r e s t a u r a n t s , cafes and public e a t i n g places generally, is t h a t of Dr. Allan. T h a t lhere could be anyone b e t t e r qualified to deal with this a s p e c t of the subject it is impossible to believe, and it is certain t h a t no one could have produced a fuller or m o r e i n t e r e s t i n g report. H a v i n g r e g a r d to the .extent of Dr. A l l a h ' s experience, it is not s u r p r i s i n g to find t h a t one of the possibilities to which he m a k e s p a r t i c u l a r reference is t h a t of c a r r y i n g out medical e x a m i n a tion of cooks, w a i t e r s and food handlers in these and other businesses. Both here and in w h a t is likely to prove one of the m o s t useful of the series of m o n o g r a p h s prepared for the Committee, in which he has summ a r l s e d the laws reIating to food in v a r i o u s countries and cities t h r o u g h o u t the world, Dr. Allan goes very fully into this question of the food handler and the m e t h o d s t h a t m a y be a d o p t e d with a view to o b t a i n i n g control over him. R e f e r r i n g p a r t i c u l a r l y to the case of the hotel and r e s t a u r a n t employee, he states t h a t it is desirab'_e t h a t owners of such places " s h o u l d require a p p l i c a n t s to produce evidence of g o o d health and t h a t t h e y are not c a r r i e r s before b e i n g t a k e n on their staff, and a r e c o m m e n d a t i o n to t h a t effect m i g h t be issued by local authorities, t h o u g h it does not a p p e a r practicable t h a t this can be insisted u p o n . " In o t h e r directions also, he indicates, practical difficulties m i g h t arise, and in s u p p o r t of this view he quotes the experience of a
1926.
PUBLIC HEALTH.
n u m b e r of cities, in the United S t a t e s p a r t i c u l a r l y , where t h o u g h r e g u l a t i o n s r e q u i r i n g periodical and other medical e x a m i n a t i o n s have been made, on account of i n a d e q u a t e health staffs, these e x a m i n a tions and the g r a n t i n g of a certificate have had to be left to the i n d i v i d u a l ' s own medical a t t e n d a n t . Such an a r r a n g e m e n t , in m a n y areas, is not reg a r d e d as a reliable a l t e r n a t i v e to e x a m i n a t i o n and certification by an official of the health authority. Not unnaturally, this possibility of d a n g e r from the handler is one that a g i t a t e d the minds of m a n y of the i n v e s t i g a t o r s , and very few of the monog r a p h s but contain reference to it. Dr. Cates, for e x a m p l e , in the short note which he s u b m i t t e d on the m e a s u r e s necessary to ensure the distribution of clean bread and confectionery, s t a t e s definitely and categorically his opinion t h a t " Reg u l a t i o n s should be made enforcing the observance of cleanliness in the worker, and no w o r k e r should be p e r m i t t e d to p r e p a r e or handle food until a medical certificate of s a t i s f a c t o r y health has been given by an a p p r o v e d medical e x a m i n e r . " In the r e p o r t on ~;roceries contributed by Sir W i l f r e d B e v e r i d g e there is merely reference to the fact t h a t t h e r e is risk of c o n t a m i n a t i o n as a result of h a n d l i n g of food and the conveyance of disease by infected fingers. In this m o n o g r a p h , in which there are references to articles of diet not commonly considered by those interested in food cleanliness, the m a t e r i a l s chleflv liable to c o n t a m i n a t i o n are s t a t e d to be s u g a r , biscuits, cereals, tea, salt, and dried fruits. In r e g a r d to each one of these the reporter has some point to m a k e that is of i m p o r t a n c e from the point of view of c o n t a m i n a t i o n and t h a t is a p t to be overlooked. In the case of salt, for example, the fact t h a t it is g e n e r a l l y h y g r o s c o p i c and that the d a n g e r of c o n t a m i n a t i o n is therefore enhanced is noted and the a m o u n t of exposure and the risks associated so f a r as r e g a r d s dried f r u i t s - - r a i s i n s , candied p e e l , c u r r a n t s , figs and p r u n e s - - p a r t i c u larly stressed. A p r o p o s of the articles last named, it is interesting to read w h a t Dr. W i l l o u g h b y , of the P o r t of London, has to say in his short r e p o r t on i m p o r t e d foods. On consideration this r e p o r t e r came to the conclusion that the handling of material on clocks or shipboard, from the point of view of i m p r o p e r or d a n g e r o u s contamination, is not a large factor. The chief risks, in his opinion, arise in relation to w h a t he terms " b a g g e d m a t e r i a l s , " which corn-
99
prises chiefly s u g a r , dried f r u i t s and cereals, which do not, as in .the case of b u l k c a r g o e s such as copra, oil seeds and g r a i n , u n d e r g o such proc e s s i n g in food m a n u f a c t u r e as g i v e s protection a g a i n s t any c o n t a m i n a t i o n , if the final product is to be used as food. The d a n g e r s of c o n t a m i n a t i o n in the case of the b a g g e d material, so far as docks and ships are concerned, lie in the r o t t e n n e s s of the b a g s , d a m a g e t h e r e t o by the c a r g o w o r k e r ' s carelessness with his hook, and in p r o l o n g e d s t o r a g e , when rats affect the b a g s in the s a m e w a y as does the hook of the worker. Dr. W i l l o u g h b y m a k e s reference to the m a t t e r of " sweepings " and the troubles t h a t may arise from the use of such m a t e r i a l s of which so much is heard from time to time. The practice at the P o r t of London would seem to be effective in prev e n t i n g s w e e p i n g s being used for food purposes, and it is the opinion of Dr. W i l l o u g h b y that a common practice and s t r i n g e n c y a m o n g s t sanit a r y authorities in r e g a r d to these materials is desirable. Possibly because they r e g a r d e d it as outside not only their own reference, b u t t h a t of the Committee also, n e i t h e r Dr. \ V i l l o u g h b l y nor Sir W i l f r e d B e v e r i d g e have a n y t h i n g to say as to d a n g e r s of c o n t a m i n a t i o n of dried fruits, d a t e s and figs particularly, in the c o u n t r y of origin. This is a m a t t e r to which a t t e n t i o n has recently been directed by a medical M e m b e r of P a r l i a m e n t , and if there is no o v e r - s t a t e m e n t as to the conditions under which the p a c k i n g is done, it is one in respect of which action is necessary. Dr. Orr, of Ealing, one of the r e p r e s e n t a t i v e s of our Society on the Committee, acted, a p p r o priately, as reporter on the subject of milk, ice cream, and other milk products. Beginning his consideration of the article with which he is concerned at the place of production, Dr. Orr follows it t h r o u g h all its s t a g e s , indicates the d a n g e r s to which it is exposed, and the precautions that m i g h t and should be adopted to ensure its cleanliness and safety and protection from contamination. One point upon which g r e a t stress is laid is the absolute necessity for a supply of steam, not only at the cowshed, but also at the place of distribution. C o n t a m i n a t i o n from milk vessels, which is a serious risk, can, in his opinion, be reduced to a minimum by t h o r o u g h c l e a n s i n g with a plentiful supply of hot w a t e r to which soda has been added. and by the final use of steam. One of the most valuable points made at the interview between Sir
ioo
PUBLIC HEALTH.
George N e w m a n and the C o m m i t t e e , to which 1 shall refer later, was that, t h o u g h at first sight it m i g h t a p p e a r to be ditlicult to ensure the provision of steam, at small f a r m s p a r t i c u l a r l y , experience had shown that a sufficient a m o u n t can be obtained at a quite r e a s o n a b l e initial and a very small r u n n i n g cost. In respect of h a n d l i n g of milk in course of t r a n s i t necessities referred to are the provision by railway companies of p r o p e r receiving rooms at stations, where any q u a n t i t y of milk is dealt with, and of suitable vans, which should be kept in a state of scrupulous cleanliness. To prevent cont a m i n a t i o n and interference d u r i n g transit, sealing of the churns is absolutely essential, and in order to ensure protection d u r i n g distribution satisfaction can only be obtained if b o t t l i n g is made compulsory. In the case of milk it is n o t e w o r t h y t h a t Dr. O r r avoids offering an opinion on the subject of pasteurisation, t h o u g h he p e r m i t s himself to say in respect of c r e a m t h a t it should be sold in sealed bottles and should be pasteurised. If efficiently pasteurised, he adds, cream should keep much longer than if t r e a t e d with preservatives. The subject referred to Dr. Barlow (\Vallasey), another of the r e p r e s e n t a t i v e s (~f the Society, was that relating to p r e p a r e d foods and the premises on which the p r e p a r a t i o n is carried out. The interest of Dr. Barlow in this i m p o r t a n t subject is well known, as is also the fact that the \Vallase3 Council was one of the first a u t h o r i t i e s in the country to obtain special powers to control food premises and the p r e p a r a t i o n of food. In addition to p r o v i d i n g a s u m m a r y of the provisions relating to these m a t t e r s and contained in an Act passed in 19:20, Dr. B a r l o w gives also the chief reasons foe r e g a r d i n g the g r a n t i n g cf powers as essential. T h a t m a n y of the premises now used are ill a d a p t e d for use for the p u r p o s e of p r e p a r i n g food for human consumption most of us are readv to agree. All of us also are p r e p a r e d to share in Dr. Barlow's a s t o n i s h m e n t t h a t at the p a s s i n g of the F a c t o r y and W o r k s h o p Act, 1901, the only food p r e p a r i n g premises t h o u g h t worth attention were those used for the b a k i n g of bread and confectionery. Conditions infinitely worse, as the reporter points out, are to be found in places in which the articles dealt with, p o t t e d meat, pies and fish pastes, are much more liable to c o n t a m i n a t i o n , and consequently constitute a more serious menace to health. The faults commonly found in the m a k e s h i f t premises frequently so
JANUARY,
used are lack of l i g h t and ventilation, lack of s t o r a g e a c c o m m o d a t i o n for fresh food and for w a s t e products, and insufficient w a t e r supply. In addition to these there is a further deice[ that the w o r k e r s are commonly careless and unskilled and, as a result, a possible d a n g e r to the c o n s u m e r s of the articles they make. It will be noted t h a t up to this point no reference has been m a d e to m e a t or any indication given as to w h e t h e r or not this subject was i n v e s t i g a t e d . I am not, nor w a s the Committee, unmindful of the i m p o r t a n c e a t t a c h i n g to this article of diet, and in c h o o s i n g t h e i r r e p r e s e n t a t i v e s the Council of the Royal S a n i t a r y I n s t i t u t e n o m i n a t e d Mr. J. R. H a y h u r s t , M . R . C . V . S . , the v e t e r i n a r y s u p e r i n t e n d e n t of the City C o r p o r a t i o n M a r k e t s at Isllngton. The p r i m a r y object of the C o m m i t t e e b e i n g to p r e p a r e a case for submission to the Minister (1l" H e a l t h with s u g g e s t i o n s as to action t h a t m i g h t be t a k e n , it was felt that, h a v i n g r e g a r d to the fact that r e g u l a t i o n s relating to meat had only recently come into operation, any st~tement with r e g a r d to it would lead merely to the reply t h a t provision had been made that was likely to lead to i m p r o v e m e n t s . On these g r o u n d s , and for the reason that the C o m m i t t e e t h o u g h t t h a t a n y t h i n g that m i g h t be c o n s t r u e d as criticism of r e g u l a tions actually only u n d e r g o i n g trial m i g h t weaken their general case, it was decided to accept the view of Mr. H a y h u r s t t h a t a special m e m o r a n d u m was really unnecessary. In dealing with the reports, I have so far limited myself, in the main, to referring to some of the more i m p o r t a n t m a t t e r s in connection with l b c c o n t a m i n a t i o n of v a r i o u s foods as a result of exposure and h a n d l i n g that a p p e a r e d to call for attention. This aspect, as I have indicated, was not the only one r e g a r d e d by the i n v e s t l g a t n r s , a l t h o u g h it was recognised as h a v i n g imporlance, since, all through, there was the hope that information of use to others in c a r r y i n g out educational and p r o p a g a n d a w o r k m i g h t be made available. The aspect t h a t possibly a p p e a l e d most, as j u d g e d from the r e p o r t s themselves, was that h a v i n g relation to prevention and the procedure to be a d o p t e d in each case, with a view to g e t t i n g rid of risks and d a n g e r s of c o n t a m i n a t i o n of the p a r t i c u l a r article of food. This it was, indeed, that it w a s desired most s t r o n g l y to put before the Minister. R e a s o n s for the r e c o m m e n d a t i o n of any p a r t i c u l a r kind of action n a t u r a l l y also it was desired to offer and here, it will p r o b a b l y not be found surprising,
1926.
PUBLIC HEALTH.
the Committee encountered the chief of its difficulties. W i t h o u t any hesitation whatever in the final report the Committee declared that from the memoranda it appeared " t h a t Great Britain was practically alone a m o n g s t the more advanced of the nations in having failed to take cognizance of the existence of risk to health and of the production of disease, as a result of defective and careless exposure and handling of food, and to provide legislation for the protection of the people from such r i s k s . " As a matter of fact, upon the reports, they could readily make such a declaration, pointing to the statements made by the observers as to the failure to provide protection for the articles when exposed for sale and the handling to which they were subjected in the course of sale and preparation for sale. That there is risk of contamination is obvious, and can be enlarged upon to any extent. W h a t the contaminations may be can also be described, and what the effects might be if one or other of certain particular contaminations occurred. At this point, however, difficulties begin to arise, since it is impossible to give a definite reply to an enquiry as to the extent of the risk of these particular contaminations occurring, or to deny that their existence alone is hardly sufficient to justify interference with long established practices. Dr. K e n w o o d himself in a report submitted on the subject of fish, states that th e cooking process is adequate to ensure safety for the consumer, and in the case of any food that undergoes cooking, it it impossible to do ottmr than admit that in all probability the risks to which it has been exposed before it is actually put upon the fire will probably have been deprived of their effect by the application of heat. Indeed, I feel that under cross-examination, not one member of the Committee but would be driven to agree that, in the case of most foods, the risk of occurrence of any specific disease or even easily recognizable interference with health, as a result of the treatment suffered at the hands of the traders, is somewhat remote. Probably because criticism on this point was anticipated, the Committee in its Final Report took the opportunity of referring specifically to it and with a view, no doubt, to disarming the critic introduced the following statement : " I t is recognised that the objections urged against the methods adopted are less on the public health than the aesthetic side, and that little or no definite evidence of injury to health
101
is offered. The difficulties in the way of producing such evidence are, however, enormous, and in any case, and fortunately, it is only very rarely that anything in the shape of definite disease is traceable to food contaminated as a result of careless handling or exposure. Vague disturbances of health and digestion that may be caused by such contaminations are rarely particularly noted and practically never investigated. Even if aesthetic grounds are those that alone can be established, the Committee feel strongly that, having regard to the great variety of conditions that may, and do affect food, and exert an influence in relation to its nutritive qualities, they are sufficiently strong to justify legislative action with a view to securing adequate supervision and the exercise of such c a r e and cleanliness as will ensure the decency that the increasing refinement of the people demands and that the changed conditions, the result of the intensified urbanization of this country, c o m p e l . " The action that the Committee recommended should be taken, even if it is regarded as having for its object merely the remedying of an aesthetic defect, or what is to some extent the same thing, the ploduction of an educational and psychological effect a m o n g s t the people, cannot be regarded as other than extremely moderate. " T o the question as to the line that should be taken in providing the legislation held to be necessary in order to ensure control and protection of the health interests of the consumer in relation to the distribution and marketing of food, the C o m m i t t e e " says the report, " h a v e given much consideration. In the Public Health (Regulations as to Food) Act, 1907, the Minister of Health, it seems clear, has adequate powers to make regulations relating to food and covering most of the aspects that have been referred to. Under these powers several sets of regulations have already been issued, the latest being the Public Health (Meat) Regulations, 1924, already mentioned. That the power given is sufficiently extensive to permit of the introduction of a requirement calling for Registration is perhaps open to question ; but if such power is absent then it should be sought at the earliest moment. T h a t the Minister of Health considers the most satisfactory method of procedure is by way of separate regulations relating to each food would appear to be indicated by the regulations already issued. That this is the opinion of local authorities also is
102
PUBLIC H E A L T H .
JANUARY,
s u g g e s t e d by the fact t h a t several, as shown in the m e m o r a n d a of Dr. Allan a n d Dr. Barlow, have included provisions in local Acts o1 Parliament, most of them r e l a t i n g to meat and meat p r o d u c t s alone. In the opinion of the Committee procedure and a d m i n i s t r a t i o n would be g r e a t l y simplified if one set of r e g u l a t i o n s were issued c o n t a i n i n g provisions affecting the several m a t t e r s that are c o m m o n to all foods, such as t r a n s p o r t and, if possible, r e g i s t r a t i o n , and a g e n e r a l prohibition of e x p o s u r e of meat, fruit, sweets and the more i m p o r t a n t and readily cont a m i n a t e d articles on the s t r e e t ; r e s e r v i n g s e p a r a t e r e g u l a t i o n s for any t r a d e or article, e.g., bread, t h a t called for specific regulation. In the United S t a t e s of A m e r i c a a n d other countries, as shown by Dr. Allan in his s u m m a r y of foreign regulation.4, it a p p e a r s to be the practice to deal with each t r a d e by means of s e p a r a t e regulations. It is noted, also, that in the S t a t e s the m a k i n g of the r e g u l a t i o n s is in the hands of the local authorities. This method, the C o m m i t t e e would s u g g e s t , has m a n y advant a g e s , and in connection t h e r e w i t h desire to r e c o m m e n d to the Minister of H e a l t h the adoption of this practice, which in fact a l r e a d y exists in relation to sanitation, p o w e r s to m a k e by-laws being in the h a n d s of the local authorities, the central body securing control by f o r b i d d i n g the operation of the provisions until a p p r o v e d by them and by i s s u i n g model b y - l a w s for the guidance of a local b o d y . " To these s u g g e s t i o n s Sir G e o r g e N e w m a n who, as already stated, received the C o m m i t t e e on behalf of the Minister, and u n d e r t o o k to report the results of the interview to him, a p p e a r e d to t a k e no exception. His a t t i t u d e t h r o u g h o u t indeed was most sympathetic, and the discussion that followed the submission of the r e p o r t s and the additional p a r t i c u l a r s given by v a r i o u s of the inv e s t i g a t o r s was c h a r a c t e r i z e d by the utmost friendliness.
require much, if any, modification before they c a m e into o p e r a t i o n . F u r t h e r , he referred to the effect likely to be p r o d u c e d by the Milk and Dairies (Consolidation) Act, 1915, and by Section 7'2 of the Public H e a l t h Act, 1925. In reghrd to the former he mentioned that r e g u l a t i o n s under the Act were now in draft, and would be sent to our Society, in order t h a t the m e m b e r s m i g h t have an o p p o r t u n i t y of c o n s i d e r i n g them, and if t h o u g h t necessary offering s u g g e s t i o n s . T h a t Sir G e o r g e N e w m a n is justified in c l a i m i n g that the F o o d Section of the M i n i s t r y has done e x t r a o r d i n a r i l y g o o d w o r k and t h a t g r e a t , even r e m a r k a b l e p r o g r e s s , has b e e n made since the Section was c r e a t e d no one will deny. At the m e e t i n g with Sir G e o r g e N e w m a n it was explained on behalf of the C o m m i t t e e that their one wish was to help the Section ; not to e m b a r a s s but to second their efforts. In a n y t h i n g t h a t I have said already, and m a y yet say, I have been a n i m a t e d by the s a m e spirit. The C o m m i t t e e h a d no desire to carp or to critielse, nor have I, when I say that g r e a t as the prog r e s s m a d e m a y have been it is much less than in m a n y other c o u n t r i e s it has been and i s ; much less than it should or m i g h t have been. On behalf of the M i n i s t r y it was hinted at the time of our visit t h a t there were m a n y reasons of policy and political, where G o v e r n m e n t d e p a r t ments were concerned, t h a t rendered delay inevitable. T h a t this is true, and t h a t it is equally so t h a t we who are outside m a y find it impossible to a p p r e ciate quite how difficult the situation m a y be at times, and how m a n y and v a r i e d are the interests that m u s t be considered, cannot be doubted. All the same, it is h a r d for us to believe sometimes that the M i n i s t r y in some cases is quite as d a r i n g as it m i g h t be : that too read): an ear is not lent to those w h o t h r e a t e n or p r o g n o s t i c a t e failure, and t h a t the service of the winds in d e a l i n g with caution are sufficiently made use of.
In his reply, Sir G e o r g e drew attention to the a m o u n t of w o r k in connection with food that had a l r e a d y been done by the Ministry, and t h a t which is in contemplation. P a r t i c u l a r l y , he mentioned the s e t t i n g up of a F o o d Section under the c h a r g e of Dr. M a c F a d d e n ; the c o m i n g into operation of the R e g u l a t i o n s as to F o o d Act in 1907, and the n u m b e r of r e g u l a t i o n s a l r e a d y issued under powers g r a n t e d by the Act. A m o n g s t r e g u l a t i o n s he referred specifically to the Public H e a l t h (Meat) R e g u l a t i o n s , 1924, and to those more recently issued with r e g a r d to p r e s e r v a t i v e s and colouring m a t t e r in foods, which he anticiI)ated would not
In the case of the p e o p l e s ' food, it is to my mind easy to e x a g g e r a t e the fear of the consequences t h a t m a y follow if action likely to disturb the e s t a b l i s h e d p r a c t i c e s of any concerned in the t r a d e is taken. T o the c o m m e r c i a l l y minded, the individual who has the money sense well developed, and who t a k e s up business for r e a s o n s other than the purely hygienic, the food t r a d e is e x t r a o r d i n a r i l y a t t r a c tive. The profits are g o o d , the t u r n - o v e r is quick, and there is little or no w a i t i n g for money. Because of these t h i n g s there need be no fear t h a t there will ever be any hesitation about enter-
1926.
PUBLIC HEALTH.
ing the business, or that those who are in it will be driven out by conditions imposed by law, and that there will be interference, therefore, with food supply. Such as are driven out, indeed, will be only those who o u g h t never to have 1)een in, and the people instead of being embarassed will be benefitted bv the loss. The situation is entirely different from that in the case of that other prime necessity, housing, in which it would appear much of the present e m b a r r a s s m e n t from which the people are sufferin K is the result of legislative and administrative interference. Those who provided or might have provided h o u s i n g have been driven out of the business because of the onerous conditions imposed. As a business, however, house providing has few, if any, attractions to compare with those offered by food trading. F o r one thing, the profits are much less, and there is no till into which money is continually flowing and where it can be handled. There is little in fact to tempt an individual to enter the house business or to make sacrifices to remain in it, and so we find that the authorities have become or are rapidly c o m i n g to be the one and only h o u s i n g providers. Bv th{'se who are or would like to be in the food business, cn the other hand, sacrifices would willingly be made, legislation compelling what would be cried out upon as sacrifices would be complied with, and there is little likelihood of the g o v e r n i n g t)odies being allowed to become traders in food. Make any regulations that appear to be necessary, impose any restrictions that the case requires as regards licensing or registratii.'n {~f food premises or food dealers, the only effects produced wilt be such as are eminently desirable. Only the incompetent and ill-quallfied will be debarred from the t r a d e ; the individual who is in it or w a n t s to enter only because it appears to be easy and because profits are easily and quickly made ; the individual, in fact, who (mght not to be permitted to have a n y t h i n g to do with food, to ot)t:-l]II a n y t h i n g like a vested interest in the food business. T h a t the food business is one of the big vested interests, and is certain to become greater, must be admitted, b u t if we must accept it as a vested interest it is of much importance that e v e r y t h i n g should be done to g u a r d a g a i n s t anvone o b t a i n i n g a footing in it who is not properly qualified to occupy a place. H a v i n g regard to the importance of food, it has often occurred to me to wonder how it has come
103
about that we have allowed so much of indiscrlmination is respect of tile trade in it, and why, of all the four prime necessities of the llfe and health cf the people--air, water, food and shelter--food should always have been treated as the Cinderella. F r o m the very b e g i n n i n g of health lcgislation there have been attempts made to prevent the pollution of air, indoors bv prohibiting overcrowding and outdoors by interfering with the offensive trades, by forbidding |he emission of smoke and otherwise. In the case of water, the law has compelled tlne people individually to take precautions against c o n t a m i n a t i o n by looking after their sanitary conveniences, their drains and cisterns, and has seen to it that collectively they expended vast sums of money in providing an adequate supply of pure water and in keeping it free from contamination. Of the bulk of the Iaw relating to housing, and of the sums expended in the e n d e a v o u r to secure proper housing for the people, it is unnecessary to remind you. Nor would I remind you of the great part the people have played in forcing the authorities to take action, did I not wish to compare the activity of the public in this regard with lheir supineness in the matter of food. Neither individually nor collectively do the people appear to take much interest. Let the Minister of Health so much as hint that he is satisfied with the progress made in regard to housing, or let him m e n t i o n that he has been t h i n k i n g of the Rent Restriction Act, and at once the population seethes with excitement. " P a t e r f a m i l i a s " and " V o x P o p u l i " and " A n Old C o n t e m p t i b l e " write letters to the editor; the pictorial Press provides its readers with a picture or two of families living in tents and vans ; we a~,e overwhelmed with complaints of dirty walls and ceilings and choked drains ; full dress debates take place in every council c h a m b e r in the c o u n t r y ; Labour Members execrate property owners and their opponents, and somebody or other, with the assistance of a countess and a few dukes, starts a new society. Has anybody ever set up a league to compel local authorities and food traders to ensure cleanliness in regard to food; has anybody ever heard of a society with regard to food except those formed by the simple souls who desire to increase the consumption of whole meal bread or nuts or raw potatoes ? How many complaints do we receive in our departments that the meat regulations are n¢;t being observed bv this, that or the other t r a d e r ;
104
PUBLIC HEALTH.
w h a t evidence has there been of interest on the p a r t of the g e n e r a l public in the r e g u l a t i o n s reg a r d i n g food preservatives, or in any other legislation or a d m i n i s t r a t i v e w o r k aimed at i m p r o v i n g conditions under which food is sold o r prepared for sale? T h a t there has been little or none m u s t be admitted, and it m u s t be a d m i t t e d too t h a t this is largely because a g e n e r a l sense of fastidiousness in this connection has not been developed, and the public have not been t a u g h t how essential are care and cleanliness in relation to food. Of the existence of a need for e d u c a t i n g the public up to a recognition of the defects and the objectionableness of present-day m e t h o d s the Joint C o m m i t t e e are a w a r e , and it is one of their proposals t h a t the v a r i o u s reports should be published and circulated as widely as possible, so t h a t publicity m a y be obtained. T h a t the publication will c a r r y m a t t e r s very far in the direction desired is too much to expect. W h a t is hoped, however, is t h a t even t h o u g h the reports m a y fail to reach the h a n d s of the people it is desired chiefly to affect, they m a y reach and appeal to and help those w h o can secure the public ear and pour into it the t e a c h i n g t h a t a p p e a r s to be so desirable. No one has readier access to this ear than the medical officer of health, and if the publication were dedicated to anyone, there is none to whom it could more a p p r o p r i a t e l y go. A suitable wish t h a t m i g h t a c c o m p a n y the act of dedication would be that the information provided m i g h t prove useful, and b e i n g readily available, should lead to a s a v i n g of trouble and time and labour in c a r r y i n g out p r o p a g a n d a and educational w o r k on this subject. Personally, I have no r i g h t ~o m a k e any such dedication or to express such a wish on behalf of the Committee. W i t h o u t hesitation, however, [ c o m m e n d the reports to you and to all medical officers of health, and s u g g e s t t h a t the g r o u n d that has been covered by the C o m m i t t e e is one t h a t it would be an a d v a n t a g e if our people could be made also to traverse, m o r e p a r t i c u l a r l y if the medical officer of health g o e s with them as their guide, lecturer and friend.
The salary of Dr. Meredith Young as County medical officer of health of Cheshire has been increased by £150 per annum, viz., to £1,550; and the salary of Dr. Jean Shaw, lady assistant medical officer, to £725 per annum, from 1st July, 19,95, and £750 per annum from 1st July, 1926,
JANUARY,
SERUM
TREATMENT OF SCARLET FEVER. By E. H. R. HARRIES, M . D . , Lond. D . P . H . Medical Superintendent, Birmingham City Hospitals. In the l i g h t of the newer k n o w l e d g e g a i n e d of the m e c h a n i s m of the disease, Z i n g h e r (1) defines the modern conception of scarlet fever as follows : " A local d i s e a s e of the n a s o p h a r y n g e a l mucous m e m b r a n e , caused by certain specific strains of the hmmolytie streptococcus. A soluble toxin is p r o d u c e d locally which is a b s o r b e d into the svstem of the patient and gives rise to the rash and constitutional s y m p t o m s . T h e toxin paves the w a y for the s e c o n d a r y invasion of the system by the specific hsemolytic s t r e p t o c o c c u s and other o r g a n i s m s p r e s e n t in the bacterial flora of the nasopharyngeal cavities." The Dicks (2) state that " t h e sterile toxin alone is c a p a b l e of p r o d u c i n g the c h a r a c t e r i s t i c s y m p t o m s of scarlet fever including the rash, and t h a t minute quantities of toxin will p r o d u c e s y m p t o m s in susceptible a d u l t s . " I t m a y or m a y not prove that these s t a t e m e n t s contain the whole t r u t h of the m a t t e r , b u t all i n v e s t i g a t i o n w o u l d seem to show t h a t they contain so much of it t h a t they m a y b e - - a s they are b e i n g - - e m p l o y e d as a basis from which to perfect a rational specific t h e r a p y for a disease affalnst which to all intents and p u r p o s e s we h a v e hitherto only had available the uncertain w e a p o n s of s y m p t o m a t i c t r e a t m e n t . N e v e r t h e l e s s when d i s c u s s i n g the results of t r e a t ment of a specific d i s e a s e by a t h e r a p e u t i c serum, it is n e c e s s a r y to c o n s i d e r to w h a t e x t e n t the effect - - i f a n y - - h a s been p r o d u c e d by each of at least three p r o p e r t i e s which the serum m a y possess. T o what e x t e n t have the results been due to (a) the serum itself, i.e., non-speclfic p r o t e i n t h e r a p y , (b) specific a n t i - b a c t e r i a l properties, (c) specific antitoxic properties. The difficulties of e s t i m a t i n g and especially of p r e s e n t i n g g r a p h i c a l l y the results of any one form of t r e a t m e n t in scarlet fever or of c o m p a r i n g the results o b t a i n e d by one means with those o b t a i n e d by o t h e r m e a n s a r e very soon borne in upon anyone who e s s a y s the task. In p r e p a r a t i o n for this paper, I have analysed some 1,500 recent scarlet fever case sheets and charts, and I v e n t u r e to say t h a t so far as a t e m p e r a t u r e c h a r t can depict, I can p r o d u c e - - w e all c a n - - p r a c t i c a l l y identical c h a r t s of similar clinical t y p e s of e a s e - - a b s o l u t e clinical identity of course does not e x i s t - - w h i c h have had (a) no
1926. CLEAN
FOOD. ~
By CHARLES PORTER, M.D., B.Sc., M . R . C . P . , Ed., Medical Officer of Health, St. Marylebone.
My chief reason for choosing this as the subject of my Presidential address is that it gives an o p p o r t u n i t y of expressing appreciation of the efforts of a n n m b e r of colleagues in this and other Branches of the Society, and of m a k i n g use of work done and m o n o g r a p h s prepared by them in reporting progress in a matter we are all interested in and to which I personally drew attention in a paper read at the Royal S a n i t a r y I n s t i t u t e Congress at Liverpool in 1!)24. In this paper, in addition to g i v i n g my imp:ressions of American methods of food handling, 1 also expressed s t r o n g views on our own s h o r t c o m i n g s in this regard. C l a i m i n g for us, as a nation, that so far as regards table m a n n e r s we were the most precise on earth, and as eaters the cleanest and most fastidious, I had to point out that in the matter of food itself, its production and protection, we were, of the more progressive peoples, probahly the most neglectful. R e g a r d i n g this as a proposition likely to be selfevident to the members of my audience, I did not take the trouble to give much in the shape of proof. I did no more, in fact, than indulge in generalities and offer s u g g e s t i o n s as to what l t h o u g h t should be done with a view to o b t a i n i n g improvements. The chief of these s u g g e s t i o n s had relation to education and p r o p a g a n d a , which I held to be necessarv in the case of the public, the traders, and the legislature. Of the three the most i m p o r t a n t appeared to me to be the public, since if desire for information could be awakened a m o n g s t the people, very soon the need for m a k i n g and enforcing these i m p r o v e m e n t s would be recognised bv the traders and the legislature. Education of the traders I regarded as more or less a hopeless task for us to undertake. The influencing of the legislature, t h o u g h perhaps not quite so hopeless, it seemed could be done very much more effectively by the public. So far as the traders were concerned, I counselled that we should make no special effort in the n a t u r e of a direct attack, r e c o m m e n d i n g rather that we should concentrate upon the people and devote some of the time that we were g i v i n g to medical p r o p a g a n d a , to teaching facts with * Presidontial Address 1o Motropolitar., Branch, Society o f Medical Ofl~c¢'rs of l lealth, November 27th, 1925,
97
regard to food and to o p e n i n g eyes to the necessity for cleanliness in regard to it. The legislature I did not feel we could leave alone entirely. I recommended, therefore, that there should be set up a special committee jointly by the Society and the Royal S a n i t a r y Institute, whose reference should be, after considering the whole matter, to approach the Minister of Health in order to urge him to a m e n d existing legislation and to provide new laws g o v e r n i n g the preparation and sale of food, and r e q u i r i n g that all persons concerned in its production, preparation or sale shall take all precautions necessary to ensure its proper cleanliness and freedom from contamination. So far as my knowledge goes tile only one of these suggestions that has been adopted is that relating to the s e t t i n g up of a Joint Committee. Education and p r o p a g a n d a a m o n g s t the people may have been g o i n g on and, as I said in my paper, some of us may have stopped t a l k i n g about teeth and a d v i s i n g the c o n s u m p t i o n of four glasses of water per day for a season, c o n c e n t r a t i n g instead on the g i v i n g of such instruction as would lead housewives and others to attack food producers and vendors and the G o v e r n m e n t , and compel them to mend their ways. This I do not know, but I have not seen mtwh evidence of it. The recommendation as to the s e t t i n g up of the Joint Committee was not only accepted, but was acted upon. Nay, more, the Committee has done its work, has approached the Minister, and has been received, if not by himself personally, then by his Chief Medical Officer acting as his representative. It is of these things that I would now speak. The Committee appointed by ourselves and the Institute was an exceedingly representative o n e ; more than that, it was very e n t h u s i a s t i c and hardworking. T o me personally, and as your President, it is a source of gratification that no fewer than half the m e m b e r s were colleagues in the Metropolis and also M e m b e r s of this Branch. Not only so, but at the time of a p p o i n t m e n t all were or had been officers of the Branch ; three, Dr. Allan, Dr. Kenwood and Dr. W i l l o u g h b y , being past Presidents, Dr. F e n t o n , our Secretary, m a k i n g the fourth, and myself the fifth. F o r some reason or other the Committee did me the h o n o u r of a p p o i n t i n g me C h a i r m a n , and when I saw what m e m b e r s h i p of the Committee was to imply in the shape of work, and that the chair was to be practically a place of rest, I must confess that I felt rather glad that I had been put there.
98
PUBLIC HEALTH.
R e c o g n i s i n g t h a t much of the t a l k with r e g a r d to food h a n d l i n g and the neglectfulness of handlers, and the d a n g e r s a s s o c i a t e d therewith, was largely only talk and in the form of generalities, the C o m m i t t e e at its first m e e t i n g decided that the best plan to a d o p t would be to a r r a n g e for the c a r r y i n g out of as complete an investigation as possible of certain definite food trades. To this end each m e m b e r a g r e e d to t a k e up a business or an aspect of the question and to prepare a memorandum. The subjects i n v e s t i g a t e d and the m e m b e r s t a k i n g responsibility for the p r e p a r a t i o n of the m o n o g r a p h s were : - (a) Meat and M e a t P r o ducts ...... Mr. J. R. H a y h u r s t , M.R.C.V.S. Prof. H. R. Ken(b) F i s h ... wood, C . M . G . , M.B. (c) F r u i t and VegeJ. F e n t o n , M.D. tables . . . . . . (d) Bread and ConfecJ,~seph Cates, M.D. tionery . . . . . . (e) Milk, Ice Cream, Thomas Orr, M.D., etc . . . . . . . D. Sc. Sir W i l f r e d Beveridge, (f) Groceries . . . . . . K . B . E . , C.B., D . S . O . (g) R e s t a u r a n t s and F. J. Allan, M.D. Cafes . . . . . . (h) F o o d R e g u l a t i o n s , Licensing and Registration of Premises ... F. J. Allan, M.D. (i) P r e m i s e s where Prepared Food is Made ... T. \V. N a y l o r Barlow, O . B . E . , M.D. (j) I m p o r t e d F o o d s ... Yr. M. W i l l o u g h b y , M.D. The a d v a n t a g e s of such an a r r a n g e m e n t must l~e obvious and were enormous. T h e n u m b e r of inv e s t i g a t o r s who had little to do or say w a s small, most of the businesses affording an a s t o n i s h i n g a m o u n t of scope and the i n v e s t i g a t i o n s revealing the existence of a g r e a t m a n y more opportunities for contamination, and a g r e a t e r a m o u n t of uncleanliness even, than had ever been referred to in the general indictments c o m m o n l y heard. This, no doubt, was to be expected, since, in the main, the i n v e s t i g a t i o n s were p r o p e r l y planned and methodically carried out. As a model I would c o m m e n d to you the report of Dr. F e n t o n , w h o u n d e r t o o k to enquire into the t r a d e of fruit and v e g e t a b l e s . A l o n g with the
JANUARY,
o t h e r r e p o r t s this will, I hope, be published, and as you will all of you I know read it, it is unnecessary for me to discuss it at any length. The only t h i n g I desire to do, and as illust r a t i n g the point just made, with r e g a r d to method, is to point out t h a t from his report it is clear t h a t Dr. F e n t o n b e g a n his o b s e r v a t i o n of v e g e t a b l e s and fruit intended for h u m a n food consumption at the b e g i n n i n g , and followed them from the m a r k e t g a r d e n and the orchard, t h r o u g h the hands of the p i c k e r s and p a c k e r s and carriers, to the retailers and costers, and eventually to tile consumer. Of the c o n t a m i n a t i o n s to which they are liable at all s t a g e s none a p p e a r s to be overlooked, from those that m a y be picked up from the soil in which they are g r o w n , to those that may be acquired from i m p r o p e r l y t r a i n e d dogs, when the g o o d s are stacked, as is so often the case, on the streets and p a v e m e n t s outside shops and m a r k e t s . A n o t h e r r e p o r t which I am certain will appeal to all, and will be p a r t l c u l a r l y i n t e r e s t i n g and helpful to those of us whose districts are rich in r e s t a u r a n t s , cafes and public e a t i n g places generally, is t h a t of Dr. Allan. T h a t lhere could be anyone b e t t e r qualified to deal with this a s p e c t of the subject it is impossible to believe, and it is certain t h a t no one could have produced a fuller or m o r e i n t e r e s t i n g report. H a v i n g r e g a r d to the .extent of Dr. A l l a h ' s experience, it is not s u r p r i s i n g to find t h a t one of the possibilities to which he m a k e s p a r t i c u l a r reference is t h a t of c a r r y i n g out medical e x a m i n a tion of cooks, w a i t e r s and food handlers in these and other businesses. Both here and in w h a t is likely to prove one of the m o s t useful of the series of m o n o g r a p h s prepared for the Committee, in which he has summ a r l s e d the laws reIating to food in v a r i o u s countries and cities t h r o u g h o u t the world, Dr. Allan goes very fully into this question of the food handler and the m e t h o d s t h a t m a y be a d o p t e d with a view to o b t a i n i n g control over him. R e f e r r i n g p a r t i c u l a r l y to the case of the hotel and r e s t a u r a n t employee, he states t h a t it is desirab'_e t h a t owners of such places " s h o u l d require a p p l i c a n t s to produce evidence of g o o d health and t h a t t h e y are not c a r r i e r s before b e i n g t a k e n on their staff, and a r e c o m m e n d a t i o n to t h a t effect m i g h t be issued by local authorities, t h o u g h it does not a p p e a r practicable t h a t this can be insisted u p o n . " In o t h e r directions also, he indicates, practical difficulties m i g h t arise, and in s u p p o r t of this view he quotes the experience of a
1926.
PUBLIC HEALTH.
n u m b e r of cities, in the United S t a t e s p a r t i c u l a r l y , where t h o u g h r e g u l a t i o n s r e q u i r i n g periodical and other medical e x a m i n a t i o n s have been made, on account of i n a d e q u a t e health staffs, these e x a m i n a tions and the g r a n t i n g of a certificate have had to be left to the i n d i v i d u a l ' s own medical a t t e n d a n t . Such an a r r a n g e m e n t , in m a n y areas, is not reg a r d e d as a reliable a l t e r n a t i v e to e x a m i n a t i o n and certification by an official of the health authority. Not unnaturally, this possibility of d a n g e r from the handler is one that a g i t a t e d the minds of m a n y of the i n v e s t i g a t o r s , and very few of the monog r a p h s but contain reference to it. Dr. Cates, for e x a m p l e , in the short note which he s u b m i t t e d on the m e a s u r e s necessary to ensure the distribution of clean bread and confectionery, s t a t e s definitely and categorically his opinion t h a t " Reg u l a t i o n s should be made enforcing the observance of cleanliness in the worker, and no w o r k e r should be p e r m i t t e d to p r e p a r e or handle food until a medical certificate of s a t i s f a c t o r y health has been given by an a p p r o v e d medical e x a m i n e r . " In the r e p o r t on ~;roceries contributed by Sir W i l f r e d B e v e r i d g e there is merely reference to the fact t h a t t h e r e is risk of c o n t a m i n a t i o n as a result of h a n d l i n g of food and the conveyance of disease by infected fingers. In this m o n o g r a p h , in which there are references to articles of diet not commonly considered by those interested in food cleanliness, the m a t e r i a l s chleflv liable to c o n t a m i n a t i o n are s t a t e d to be s u g a r , biscuits, cereals, tea, salt, and dried fruits. In r e g a r d to each one of these the reporter has some point to m a k e that is of i m p o r t a n c e from the point of view of c o n t a m i n a t i o n and t h a t is a p t to be overlooked. In the case of salt, for example, the fact t h a t it is g e n e r a l l y h y g r o s c o p i c and that the d a n g e r of c o n t a m i n a t i o n is therefore enhanced is noted and the a m o u n t of exposure and the risks associated so f a r as r e g a r d s dried f r u i t s - - r a i s i n s , candied p e e l , c u r r a n t s , figs and p r u n e s - - p a r t i c u larly stressed. A p r o p o s of the articles last named, it is interesting to read w h a t Dr. W i l l o u g h b y , of the P o r t of London, has to say in his short r e p o r t on i m p o r t e d foods. On consideration this r e p o r t e r came to the conclusion that the handling of material on clocks or shipboard, from the point of view of i m p r o p e r or d a n g e r o u s contamination, is not a large factor. The chief risks, in his opinion, arise in relation to w h a t he terms " b a g g e d m a t e r i a l s , " which corn-
99
prises chiefly s u g a r , dried f r u i t s and cereals, which do not, as in .the case of b u l k c a r g o e s such as copra, oil seeds and g r a i n , u n d e r g o such proc e s s i n g in food m a n u f a c t u r e as g i v e s protection a g a i n s t any c o n t a m i n a t i o n , if the final product is to be used as food. The d a n g e r s of c o n t a m i n a t i o n in the case of the b a g g e d material, so far as docks and ships are concerned, lie in the r o t t e n n e s s of the b a g s , d a m a g e t h e r e t o by the c a r g o w o r k e r ' s carelessness with his hook, and in p r o l o n g e d s t o r a g e , when rats affect the b a g s in the s a m e w a y as does the hook of the worker. Dr. W i l l o u g h b y m a k e s reference to the m a t t e r of " sweepings " and the troubles t h a t may arise from the use of such m a t e r i a l s of which so much is heard from time to time. The practice at the P o r t of London would seem to be effective in prev e n t i n g s w e e p i n g s being used for food purposes, and it is the opinion of Dr. W i l l o u g h b y that a common practice and s t r i n g e n c y a m o n g s t sanit a r y authorities in r e g a r d to these materials is desirable. Possibly because they r e g a r d e d it as outside not only their own reference, b u t t h a t of the Committee also, n e i t h e r Dr. \ V i l l o u g h b l y nor Sir W i l f r e d B e v e r i d g e have a n y t h i n g to say as to d a n g e r s of c o n t a m i n a t i o n of dried fruits, d a t e s and figs particularly, in the c o u n t r y of origin. This is a m a t t e r to which a t t e n t i o n has recently been directed by a medical M e m b e r of P a r l i a m e n t , and if there is no o v e r - s t a t e m e n t as to the conditions under which the p a c k i n g is done, it is one in respect of which action is necessary. Dr. Orr, of Ealing, one of the r e p r e s e n t a t i v e s of our Society on the Committee, acted, a p p r o priately, as reporter on the subject of milk, ice cream, and other milk products. Beginning his consideration of the article with which he is concerned at the place of production, Dr. Orr follows it t h r o u g h all its s t a g e s , indicates the d a n g e r s to which it is exposed, and the precautions that m i g h t and should be adopted to ensure its cleanliness and safety and protection from contamination. One point upon which g r e a t stress is laid is the absolute necessity for a supply of steam, not only at the cowshed, but also at the place of distribution. C o n t a m i n a t i o n from milk vessels, which is a serious risk, can, in his opinion, be reduced to a minimum by t h o r o u g h c l e a n s i n g with a plentiful supply of hot w a t e r to which soda has been added. and by the final use of steam. One of the most valuable points made at the interview between Sir
ioo
PUBLIC HEALTH.
George N e w m a n and the C o m m i t t e e , to which 1 shall refer later, was that, t h o u g h at first sight it m i g h t a p p e a r to be ditlicult to ensure the provision of steam, at small f a r m s p a r t i c u l a r l y , experience had shown that a sufficient a m o u n t can be obtained at a quite r e a s o n a b l e initial and a very small r u n n i n g cost. In respect of h a n d l i n g of milk in course of t r a n s i t necessities referred to are the provision by railway companies of p r o p e r receiving rooms at stations, where any q u a n t i t y of milk is dealt with, and of suitable vans, which should be kept in a state of scrupulous cleanliness. To prevent cont a m i n a t i o n and interference d u r i n g transit, sealing of the churns is absolutely essential, and in order to ensure protection d u r i n g distribution satisfaction can only be obtained if b o t t l i n g is made compulsory. In the case of milk it is n o t e w o r t h y t h a t Dr. O r r avoids offering an opinion on the subject of pasteurisation, t h o u g h he p e r m i t s himself to say in respect of c r e a m t h a t it should be sold in sealed bottles and should be pasteurised. If efficiently pasteurised, he adds, cream should keep much longer than if t r e a t e d with preservatives. The subject referred to Dr. Barlow (\Vallasey), another of the r e p r e s e n t a t i v e s (~f the Society, was that relating to p r e p a r e d foods and the premises on which the p r e p a r a t i o n is carried out. The interest of Dr. Barlow in this i m p o r t a n t subject is well known, as is also the fact that the \Vallase3 Council was one of the first a u t h o r i t i e s in the country to obtain special powers to control food premises and the p r e p a r a t i o n of food. In addition to p r o v i d i n g a s u m m a r y of the provisions relating to these m a t t e r s and contained in an Act passed in 19:20, Dr. B a r l o w gives also the chief reasons foe r e g a r d i n g the g r a n t i n g cf powers as essential. T h a t m a n y of the premises now used are ill a d a p t e d for use for the p u r p o s e of p r e p a r i n g food for human consumption most of us are readv to agree. All of us also are p r e p a r e d to share in Dr. Barlow's a s t o n i s h m e n t t h a t at the p a s s i n g of the F a c t o r y and W o r k s h o p Act, 1901, the only food p r e p a r i n g premises t h o u g h t worth attention were those used for the b a k i n g of bread and confectionery. Conditions infinitely worse, as the reporter points out, are to be found in places in which the articles dealt with, p o t t e d meat, pies and fish pastes, are much more liable to c o n t a m i n a t i o n , and consequently constitute a more serious menace to health. The faults commonly found in the m a k e s h i f t premises frequently so
JANUARY,
used are lack of l i g h t and ventilation, lack of s t o r a g e a c c o m m o d a t i o n for fresh food and for w a s t e products, and insufficient w a t e r supply. In addition to these there is a further deice[ that the w o r k e r s are commonly careless and unskilled and, as a result, a possible d a n g e r to the c o n s u m e r s of the articles they make. It will be noted t h a t up to this point no reference has been m a d e to m e a t or any indication given as to w h e t h e r or not this subject was i n v e s t i g a t e d . I am not, nor w a s the Committee, unmindful of the i m p o r t a n c e a t t a c h i n g to this article of diet, and in c h o o s i n g t h e i r r e p r e s e n t a t i v e s the Council of the Royal S a n i t a r y I n s t i t u t e n o m i n a t e d Mr. J. R. H a y h u r s t , M . R . C . V . S . , the v e t e r i n a r y s u p e r i n t e n d e n t of the City C o r p o r a t i o n M a r k e t s at Isllngton. The p r i m a r y object of the C o m m i t t e e b e i n g to p r e p a r e a case for submission to the Minister (1l" H e a l t h with s u g g e s t i o n s as to action t h a t m i g h t be t a k e n , it was felt that, h a v i n g r e g a r d to the fact that r e g u l a t i o n s relating to meat had only recently come into operation, any st~tement with r e g a r d to it would lead merely to the reply t h a t provision had been made that was likely to lead to i m p r o v e m e n t s . On these g r o u n d s , and for the reason that the C o m m i t t e e t h o u g h t t h a t a n y t h i n g that m i g h t be c o n s t r u e d as criticism of r e g u l a tions actually only u n d e r g o i n g trial m i g h t weaken their general case, it was decided to accept the view of Mr. H a y h u r s t t h a t a special m e m o r a n d u m was really unnecessary. In dealing with the reports, I have so far limited myself, in the main, to referring to some of the more i m p o r t a n t m a t t e r s in connection with l b c c o n t a m i n a t i o n of v a r i o u s foods as a result of exposure and h a n d l i n g that a p p e a r e d to call for attention. This aspect, as I have indicated, was not the only one r e g a r d e d by the i n v e s t l g a t n r s , a l t h o u g h it was recognised as h a v i n g imporlance, since, all through, there was the hope that information of use to others in c a r r y i n g out educational and p r o p a g a n d a w o r k m i g h t be made available. The aspect t h a t possibly a p p e a l e d most, as j u d g e d from the r e p o r t s themselves, was that h a v i n g relation to prevention and the procedure to be a d o p t e d in each case, with a view to g e t t i n g rid of risks and d a n g e r s of c o n t a m i n a t i o n of the p a r t i c u l a r article of food. This it was, indeed, that it w a s desired most s t r o n g l y to put before the Minister. R e a s o n s for the r e c o m m e n d a t i o n of any p a r t i c u l a r kind of action n a t u r a l l y also it was desired to offer and here, it will p r o b a b l y not be found surprising,
1926.
PUBLIC HEALTH.
the Committee encountered the chief of its difficulties. W i t h o u t any hesitation whatever in the final report the Committee declared that from the memoranda it appeared " t h a t Great Britain was practically alone a m o n g s t the more advanced of the nations in having failed to take cognizance of the existence of risk to health and of the production of disease, as a result of defective and careless exposure and handling of food, and to provide legislation for the protection of the people from such r i s k s . " As a matter of fact, upon the reports, they could readily make such a declaration, pointing to the statements made by the observers as to the failure to provide protection for the articles when exposed for sale and the handling to which they were subjected in the course of sale and preparation for sale. That there is risk of contamination is obvious, and can be enlarged upon to any extent. W h a t the contaminations may be can also be described, and what the effects might be if one or other of certain particular contaminations occurred. At this point, however, difficulties begin to arise, since it is impossible to give a definite reply to an enquiry as to the extent of the risk of these particular contaminations occurring, or to deny that their existence alone is hardly sufficient to justify interference with long established practices. Dr. K e n w o o d himself in a report submitted on the subject of fish, states that th e cooking process is adequate to ensure safety for the consumer, and in the case of any food that undergoes cooking, it it impossible to do ottmr than admit that in all probability the risks to which it has been exposed before it is actually put upon the fire will probably have been deprived of their effect by the application of heat. Indeed, I feel that under cross-examination, not one member of the Committee but would be driven to agree that, in the case of most foods, the risk of occurrence of any specific disease or even easily recognizable interference with health, as a result of the treatment suffered at the hands of the traders, is somewhat remote. Probably because criticism on this point was anticipated, the Committee in its Final Report took the opportunity of referring specifically to it and with a view, no doubt, to disarming the critic introduced the following statement : " I t is recognised that the objections urged against the methods adopted are less on the public health than the aesthetic side, and that little or no definite evidence of injury to health
101
is offered. The difficulties in the way of producing such evidence are, however, enormous, and in any case, and fortunately, it is only very rarely that anything in the shape of definite disease is traceable to food contaminated as a result of careless handling or exposure. Vague disturbances of health and digestion that may be caused by such contaminations are rarely particularly noted and practically never investigated. Even if aesthetic grounds are those that alone can be established, the Committee feel strongly that, having regard to the great variety of conditions that may, and do affect food, and exert an influence in relation to its nutritive qualities, they are sufficiently strong to justify legislative action with a view to securing adequate supervision and the exercise of such c a r e and cleanliness as will ensure the decency that the increasing refinement of the people demands and that the changed conditions, the result of the intensified urbanization of this country, c o m p e l . " The action that the Committee recommended should be taken, even if it is regarded as having for its object merely the remedying of an aesthetic defect, or what is to some extent the same thing, the ploduction of an educational and psychological effect a m o n g s t the people, cannot be regarded as other than extremely moderate. " T o the question as to the line that should be taken in providing the legislation held to be necessary in order to ensure control and protection of the health interests of the consumer in relation to the distribution and marketing of food, the C o m m i t t e e " says the report, " h a v e given much consideration. In the Public Health (Regulations as to Food) Act, 1907, the Minister of Health, it seems clear, has adequate powers to make regulations relating to food and covering most of the aspects that have been referred to. Under these powers several sets of regulations have already been issued, the latest being the Public Health (Meat) Regulations, 1924, already mentioned. That the power given is sufficiently extensive to permit of the introduction of a requirement calling for Registration is perhaps open to question ; but if such power is absent then it should be sought at the earliest moment. T h a t the Minister of Health considers the most satisfactory method of procedure is by way of separate regulations relating to each food would appear to be indicated by the regulations already issued. That this is the opinion of local authorities also is
102
PUBLIC H E A L T H .
JANUARY,
s u g g e s t e d by the fact t h a t several, as shown in the m e m o r a n d a of Dr. Allan a n d Dr. Barlow, have included provisions in local Acts o1 Parliament, most of them r e l a t i n g to meat and meat p r o d u c t s alone. In the opinion of the Committee procedure and a d m i n i s t r a t i o n would be g r e a t l y simplified if one set of r e g u l a t i o n s were issued c o n t a i n i n g provisions affecting the several m a t t e r s that are c o m m o n to all foods, such as t r a n s p o r t and, if possible, r e g i s t r a t i o n , and a g e n e r a l prohibition of e x p o s u r e of meat, fruit, sweets and the more i m p o r t a n t and readily cont a m i n a t e d articles on the s t r e e t ; r e s e r v i n g s e p a r a t e r e g u l a t i o n s for any t r a d e or article, e.g., bread, t h a t called for specific regulation. In the United S t a t e s of A m e r i c a a n d other countries, as shown by Dr. Allan in his s u m m a r y of foreign regulation.4, it a p p e a r s to be the practice to deal with each t r a d e by means of s e p a r a t e regulations. It is noted, also, that in the S t a t e s the m a k i n g of the r e g u l a t i o n s is in the hands of the local authorities. This method, the C o m m i t t e e would s u g g e s t , has m a n y advant a g e s , and in connection t h e r e w i t h desire to r e c o m m e n d to the Minister of H e a l t h the adoption of this practice, which in fact a l r e a d y exists in relation to sanitation, p o w e r s to m a k e by-laws being in the h a n d s of the local authorities, the central body securing control by f o r b i d d i n g the operation of the provisions until a p p r o v e d by them and by i s s u i n g model b y - l a w s for the guidance of a local b o d y . " To these s u g g e s t i o n s Sir G e o r g e N e w m a n who, as already stated, received the C o m m i t t e e on behalf of the Minister, and u n d e r t o o k to report the results of the interview to him, a p p e a r e d to t a k e no exception. His a t t i t u d e t h r o u g h o u t indeed was most sympathetic, and the discussion that followed the submission of the r e p o r t s and the additional p a r t i c u l a r s given by v a r i o u s of the inv e s t i g a t o r s was c h a r a c t e r i z e d by the utmost friendliness.
require much, if any, modification before they c a m e into o p e r a t i o n . F u r t h e r , he referred to the effect likely to be p r o d u c e d by the Milk and Dairies (Consolidation) Act, 1915, and by Section 7'2 of the Public H e a l t h Act, 1925. In reghrd to the former he mentioned that r e g u l a t i o n s under the Act were now in draft, and would be sent to our Society, in order t h a t the m e m b e r s m i g h t have an o p p o r t u n i t y of c o n s i d e r i n g them, and if t h o u g h t necessary offering s u g g e s t i o n s . T h a t Sir G e o r g e N e w m a n is justified in c l a i m i n g that the F o o d Section of the M i n i s t r y has done e x t r a o r d i n a r i l y g o o d w o r k and t h a t g r e a t , even r e m a r k a b l e p r o g r e s s , has b e e n made since the Section was c r e a t e d no one will deny. At the m e e t i n g with Sir G e o r g e N e w m a n it was explained on behalf of the C o m m i t t e e that their one wish was to help the Section ; not to e m b a r a s s but to second their efforts. In a n y t h i n g t h a t I have said already, and m a y yet say, I have been a n i m a t e d by the s a m e spirit. The C o m m i t t e e h a d no desire to carp or to critielse, nor have I, when I say that g r e a t as the prog r e s s m a d e m a y have been it is much less than in m a n y other c o u n t r i e s it has been and i s ; much less than it should or m i g h t have been. On behalf of the M i n i s t r y it was hinted at the time of our visit t h a t there were m a n y reasons of policy and political, where G o v e r n m e n t d e p a r t ments were concerned, t h a t rendered delay inevitable. T h a t this is true, and t h a t it is equally so t h a t we who are outside m a y find it impossible to a p p r e ciate quite how difficult the situation m a y be at times, and how m a n y and v a r i e d are the interests that m u s t be considered, cannot be doubted. All the same, it is h a r d for us to believe sometimes that the M i n i s t r y in some cases is quite as d a r i n g as it m i g h t be : that too read): an ear is not lent to those w h o t h r e a t e n or p r o g n o s t i c a t e failure, and t h a t the service of the winds in d e a l i n g with caution are sufficiently made use of.
In his reply, Sir G e o r g e drew attention to the a m o u n t of w o r k in connection with food that had a l r e a d y been done by the Ministry, and t h a t which is in contemplation. P a r t i c u l a r l y , he mentioned the s e t t i n g up of a F o o d Section under the c h a r g e of Dr. M a c F a d d e n ; the c o m i n g into operation of the R e g u l a t i o n s as to F o o d Act in 1907, and the n u m b e r of r e g u l a t i o n s a l r e a d y issued under powers g r a n t e d by the Act. A m o n g s t r e g u l a t i o n s he referred specifically to the Public H e a l t h (Meat) R e g u l a t i o n s , 1924, and to those more recently issued with r e g a r d to p r e s e r v a t i v e s and colouring m a t t e r in foods, which he anticiI)ated would not
In the case of the p e o p l e s ' food, it is to my mind easy to e x a g g e r a t e the fear of the consequences t h a t m a y follow if action likely to disturb the e s t a b l i s h e d p r a c t i c e s of any concerned in the t r a d e is taken. T o the c o m m e r c i a l l y minded, the individual who has the money sense well developed, and who t a k e s up business for r e a s o n s other than the purely hygienic, the food t r a d e is e x t r a o r d i n a r i l y a t t r a c tive. The profits are g o o d , the t u r n - o v e r is quick, and there is little or no w a i t i n g for money. Because of these t h i n g s there need be no fear t h a t there will ever be any hesitation about enter-
1926.
PUBLIC HEALTH.
ing the business, or that those who are in it will be driven out by conditions imposed by law, and that there will be interference, therefore, with food supply. Such as are driven out, indeed, will be only those who o u g h t never to have 1)een in, and the people instead of being embarassed will be benefitted bv the loss. The situation is entirely different from that in the case of that other prime necessity, housing, in which it would appear much of the present e m b a r r a s s m e n t from which the people are sufferin K is the result of legislative and administrative interference. Those who provided or might have provided h o u s i n g have been driven out of the business because of the onerous conditions imposed. As a business, however, house providing has few, if any, attractions to compare with those offered by food trading. F o r one thing, the profits are much less, and there is no till into which money is continually flowing and where it can be handled. There is little in fact to tempt an individual to enter the house business or to make sacrifices to remain in it, and so we find that the authorities have become or are rapidly c o m i n g to be the one and only h o u s i n g providers. Bv th{'se who are or would like to be in the food business, cn the other hand, sacrifices would willingly be made, legislation compelling what would be cried out upon as sacrifices would be complied with, and there is little likelihood of the g o v e r n i n g t)odies being allowed to become traders in food. Make any regulations that appear to be necessary, impose any restrictions that the case requires as regards licensing or registratii.'n {~f food premises or food dealers, the only effects produced wilt be such as are eminently desirable. Only the incompetent and ill-quallfied will be debarred from the t r a d e ; the individual who is in it or w a n t s to enter only because it appears to be easy and because profits are easily and quickly made ; the individual, in fact, who (mght not to be permitted to have a n y t h i n g to do with food, to ot)t:-l]II a n y t h i n g like a vested interest in the food business. T h a t the food business is one of the big vested interests, and is certain to become greater, must be admitted, b u t if we must accept it as a vested interest it is of much importance that e v e r y t h i n g should be done to g u a r d a g a i n s t anvone o b t a i n i n g a footing in it who is not properly qualified to occupy a place. H a v i n g regard to the importance of food, it has often occurred to me to wonder how it has come
103
about that we have allowed so much of indiscrlmination is respect of tile trade in it, and why, of all the four prime necessities of the llfe and health cf the people--air, water, food and shelter--food should always have been treated as the Cinderella. F r o m the very b e g i n n i n g of health lcgislation there have been attempts made to prevent the pollution of air, indoors bv prohibiting overcrowding and outdoors by interfering with the offensive trades, by forbidding |he emission of smoke and otherwise. In the case of water, the law has compelled tlne people individually to take precautions against c o n t a m i n a t i o n by looking after their sanitary conveniences, their drains and cisterns, and has seen to it that collectively they expended vast sums of money in providing an adequate supply of pure water and in keeping it free from contamination. Of the bulk of the Iaw relating to housing, and of the sums expended in the e n d e a v o u r to secure proper housing for the people, it is unnecessary to remind you. Nor would I remind you of the great part the people have played in forcing the authorities to take action, did I not wish to compare the activity of the public in this regard with lheir supineness in the matter of food. Neither individually nor collectively do the people appear to take much interest. Let the Minister of Health so much as hint that he is satisfied with the progress made in regard to housing, or let him m e n t i o n that he has been t h i n k i n g of the Rent Restriction Act, and at once the population seethes with excitement. " P a t e r f a m i l i a s " and " V o x P o p u l i " and " A n Old C o n t e m p t i b l e " write letters to the editor; the pictorial Press provides its readers with a picture or two of families living in tents and vans ; we a~,e overwhelmed with complaints of dirty walls and ceilings and choked drains ; full dress debates take place in every council c h a m b e r in the c o u n t r y ; Labour Members execrate property owners and their opponents, and somebody or other, with the assistance of a countess and a few dukes, starts a new society. Has anybody ever set up a league to compel local authorities and food traders to ensure cleanliness in regard to food; has anybody ever heard of a society with regard to food except those formed by the simple souls who desire to increase the consumption of whole meal bread or nuts or raw potatoes ? How many complaints do we receive in our departments that the meat regulations are n¢;t being observed bv this, that or the other t r a d e r ;
104
PUBLIC HEALTH.
w h a t evidence has there been of interest on the p a r t of the g e n e r a l public in the r e g u l a t i o n s reg a r d i n g food preservatives, or in any other legislation or a d m i n i s t r a t i v e w o r k aimed at i m p r o v i n g conditions under which food is sold o r prepared for sale? T h a t there has been little or none m u s t be admitted, and it m u s t be a d m i t t e d too t h a t this is largely because a g e n e r a l sense of fastidiousness in this connection has not been developed, and the public have not been t a u g h t how essential are care and cleanliness in relation to food. Of the existence of a need for e d u c a t i n g the public up to a recognition of the defects and the objectionableness of present-day m e t h o d s the Joint C o m m i t t e e are a w a r e , and it is one of their proposals t h a t the v a r i o u s reports should be published and circulated as widely as possible, so t h a t publicity m a y be obtained. T h a t the publication will c a r r y m a t t e r s very far in the direction desired is too much to expect. W h a t is hoped, however, is t h a t even t h o u g h the reports m a y fail to reach the h a n d s of the people it is desired chiefly to affect, they m a y reach and appeal to and help those w h o can secure the public ear and pour into it the t e a c h i n g t h a t a p p e a r s to be so desirable. No one has readier access to this ear than the medical officer of health, and if the publication were dedicated to anyone, there is none to whom it could more a p p r o p r i a t e l y go. A suitable wish t h a t m i g h t a c c o m p a n y the act of dedication would be that the information provided m i g h t prove useful, and b e i n g readily available, should lead to a s a v i n g of trouble and time and labour in c a r r y i n g out p r o p a g a n d a and educational w o r k on this subject. Personally, I have no r i g h t ~o m a k e any such dedication or to express such a wish on behalf of the Committee. W i t h o u t hesitation, however, [ c o m m e n d the reports to you and to all medical officers of health, and s u g g e s t t h a t the g r o u n d that has been covered by the C o m m i t t e e is one t h a t it would be an a d v a n t a g e if our people could be made also to traverse, m o r e p a r t i c u l a r l y if the medical officer of health g o e s with them as their guide, lecturer and friend.
The salary of Dr. Meredith Young as County medical officer of health of Cheshire has been increased by £150 per annum, viz., to £1,550; and the salary of Dr. Jean Shaw, lady assistant medical officer, to £725 per annum, from 1st July, 19,95, and £750 per annum from 1st July, 1926,
JANUARY,
SERUM
TREATMENT OF SCARLET FEVER. By E. H. R. HARRIES, M . D . , Lond. D . P . H . Medical Superintendent, Birmingham City Hospitals. In the l i g h t of the newer k n o w l e d g e g a i n e d of the m e c h a n i s m of the disease, Z i n g h e r (1) defines the modern conception of scarlet fever as follows : " A local d i s e a s e of the n a s o p h a r y n g e a l mucous m e m b r a n e , caused by certain specific strains of the hmmolytie streptococcus. A soluble toxin is p r o d u c e d locally which is a b s o r b e d into the svstem of the patient and gives rise to the rash and constitutional s y m p t o m s . T h e toxin paves the w a y for the s e c o n d a r y invasion of the system by the specific hsemolytic s t r e p t o c o c c u s and other o r g a n i s m s p r e s e n t in the bacterial flora of the nasopharyngeal cavities." The Dicks (2) state that " t h e sterile toxin alone is c a p a b l e of p r o d u c i n g the c h a r a c t e r i s t i c s y m p t o m s of scarlet fever including the rash, and t h a t minute quantities of toxin will p r o d u c e s y m p t o m s in susceptible a d u l t s . " I t m a y or m a y not prove that these s t a t e m e n t s contain the whole t r u t h of the m a t t e r , b u t all i n v e s t i g a t i o n w o u l d seem to show t h a t they contain so much of it t h a t they m a y b e - - a s they are b e i n g - - e m p l o y e d as a basis from which to perfect a rational specific t h e r a p y for a disease affalnst which to all intents and p u r p o s e s we h a v e hitherto only had available the uncertain w e a p o n s of s y m p t o m a t i c t r e a t m e n t . N e v e r t h e l e s s when d i s c u s s i n g the results of t r e a t ment of a specific d i s e a s e by a t h e r a p e u t i c serum, it is n e c e s s a r y to c o n s i d e r to w h a t e x t e n t the effect - - i f a n y - - h a s been p r o d u c e d by each of at least three p r o p e r t i e s which the serum m a y possess. T o what e x t e n t have the results been due to (a) the serum itself, i.e., non-speclfic p r o t e i n t h e r a p y , (b) specific a n t i - b a c t e r i a l properties, (c) specific antitoxic properties. The difficulties of e s t i m a t i n g and especially of p r e s e n t i n g g r a p h i c a l l y the results of any one form of t r e a t m e n t in scarlet fever or of c o m p a r i n g the results o b t a i n e d by one means with those o b t a i n e d by o t h e r m e a n s a r e very soon borne in upon anyone who e s s a y s the task. In p r e p a r a t i o n for this paper, I have analysed some 1,500 recent scarlet fever case sheets and charts, and I v e n t u r e to say t h a t so far as a t e m p e r a t u r e c h a r t can depict, I can p r o d u c e - - w e all c a n - - p r a c t i c a l l y identical c h a r t s of similar clinical t y p e s of e a s e - - a b s o l u t e clinical identity of course does not e x i s t - - w h i c h have had (a) no