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Food poisoning of chemical origin
PUBLIC HEALTH, July, 1946
I4I
rate of eight actual cases. These numbers are small, but it is one health visitor for every 200 babies and not 250 as stated noted that this finding is in agreement with the theory that in the broadsheet. Even so, such a standard is shockingly diphtheria cases treated with anti-toxin at an early stage of the low. Where the health visitor's duties are entirely confined disease do not result in lasting immunity for the patient; to children under the age of five years, then the standard therefore the best medical practice is to immunise the child should be not more than 100 babies per health visitor. One is glad to note that the fact is recognised that in modern u r b a n artificially within a few months after recovery." I n conclusion, while this survey is an important contribution areas with its frequent shifts of employment a n d the split up. to our knowledge concerning the incidence of diphtheria in a of families, it is difficult but not important to maintain the highly protected child population, it does not in many ways old conception of the family doctor. , One wonders what compare favourably with that admirable publication by the justification there is for a statement that most child Medical Researct{ Council, "The E15idemiology of Diphtheria health officers are trained in public health rather t h a n in the During the last Forty Years," by W. T . Russell, published in care of children or that their knowledge of nutrition is mostly 1943. T h e most important lesson to be learned from the survey inadequate. T h e recommendations made for the future is that complacency with regard to diphtheria immunisation structure of the child health service are along the lines already will probably result in an increased incidence of diphtheria. postulated by those immediately interested in the work. T h e Indeed, there is sopae evidence that in America sufficient value of the broadsheet is that these ideas should now reach stress has not been laid, up to the present, upon the necessity a wider public. of re-enforcing immunisation in infancy, with an additional dose of prophylactic or a Schick Test at school entrance. We Food Poisoning of Chemical Origin may go further than this in the future, and in order to avoid Food poisoning is always with us but the types prevailing an increased incidence among adolescents and the higher-age groups, endeavour to ascertain precisely by the Schick Test at any one time show considerable variation. T h e type now most commonly met with is undoubtedly that due to enterotheir level of immunity when leaving school. toxin produced under certain conditions by some types of staphylococci, and we have had a great many such outbreaks The Child Health Services right through the war. Salmonella outbreaks also have T h e broadsheet recently issued by P.E.P. on Child Health occurred but during recent years have been comparatively and Nutrition comes very appropriately at the present time, less numerous. Side by side, and perhaps more frequently coinciding as it does with the publication of the National of late, there has been a n u m b e r of food poisoning outbreaks Health Service Bill. I n the first few paragraphs it makes a in which the poisoning is due to comparatively simple Chemical very- pertinent comment that the Bill still departmentalises bodies. Those until recently were mainly arsenical poisoning, medical work between hospitals and general medical practi- some zinc poisoning from action of acid foods in zinc retainers, tioners and the local authorities in a way which cuts across antimony poisoning, usually with lemonade as the vehicle the fundamental unit of maternity services, which are essentially made in enamelled pails which contained antimony in the health rather than sickness services. However, as the broad- enamel, occasional cases of lead poisoning from food; but sheet quite truly says, it is probably the best that can be never poisoning from tin, a remarkable testimony to the nondevised without a systematic overhaul of the structural toxic properties of tin. T h e deaths from di-ehlor-cresol and other bodies found as adulterants in alcoholic drinks have machinery and functions of local government. A finger is also put on the very great weakness of the Bill been very numerous. D u r i n g ' t h e last year or so more varied types of chemical in that many of the authorities who will have child welfare duties delegated to them will lose all responsibility, for maternal food poisoning have been reported. Chiefly in America quite care. This separation of mother and child and the apparent a number of cases of cadmium poisoning have occurred. failure to recognise that they are one unit is to be deplored. T h e i r origins have all been very similar, the cadmium gaining If a great deal of damage is not to be done to the fine work access to the food from refrigerators, of which the trays or already achieved by the maternity and child welfare services other parts were plated with materials largely 'composed of then miracles of co-operation and administration will have to cadmium. Cases of fluoride poisoning have been reported be performed. T h e broadsheet does well to stress at this due to sodium fluoride (an insecticide) being used mistakenly time that the primary responsibility for bringing up healthy for table salt or baking powder. In the B.M.~. of December children must rest on the wisdom and care of their parents 8th, 1945, two outbreaks are described, the vehicles respecand that in a fully healthy society this can be achieved. I n a tively being marmalade tart and treacle tart. Both were due r6sum6 of the present child health services it is pointed out to barium carbonate, which was being used as a rat poison that even in those cases where child welfare and school health and a sack of it was placed in error in the flour store and so services were under the same authority they were often poorly became used in the pastry of the tarts. In the Quarterly co-ordinated while the separation of both these services from Bulletin of the City of New York Health Department for December, 1945, three chemical outbreaks in 1944 are the domiciliary" and institutional services could hardly b e wider. At present local authorities possess wide powers but described. I n the first about 30 workers in a war cable few definite duties, with the result that in some areas the plant complained of gastro-intestinal and nervous symptoms services are excellent but in others the standard of facilities over a period of some two weeks. T h e y all worked on the provided is low. Proper food is the greatest single factor in third floor and in the water cooler for this floor were found human health, and it is stressed that food education should crystals of potassium thiocyanate; calculations showed that a glass of water would contain about 0.48 gramme of potassium conrinue'to be a feature of our national policy. It is pointed out that continuity of medical care for each thiocyanate, a toxic dose. How the thiocyanate gained access individual Child is the ideal for a first-class service but that could not be ascertained. T h e second involved four girl this does not necessarily mean that the same doctor or the workers who suffered from nausea and vomiting five to 15 same health visitor should be concerned with the same child minutes after taking a soft drink from a local dispensing however desirable that may be. There must be a service machine. T h e water tank was co~aper-lined and through a which operates as a unit whatever the administrative back- defective valve carbonic acid gas gained access to the water ground. T h e training and qualifications of the future health department and dissolved as much as 85 parts per million visitor are discussed and the view is taken that health visitors of copper, making a glass of this water capable of causing should be confined to work directly concerned with the welfare toxic symptoms. The third outbreak involved eleven old men of children. It is suggested that a new type of visitor should who were admitted to hospital suffering from cyanosis and undertake the more general service of advice to households shock; one died. All eleven had breakfast that morning in envisaged in the Bill. There are many arguments for and the same cafeteria. T h e symptoms were due to sodium nitrite against this. What is quite certain is that if the duties of eaten partly in oatmeal and partly derived from salt shakers. the health visitor are to be greatly extended at least four times A can of salt which actually was curing salt and contained the number of health visitors will be required. T h e standard 925/o of sodium nitrite was on the shelf in the kitchen along set in war-time by the Ministers of Health and Labour was with one of ordinary salt, and the cook used it to add to the
142 oatmeal. T h e salt shakers contained varying amounts of sodium nitrite, some having only faint traces, others as high as 0.187%. Some 125 people were served in the cafeteria and many took oatmeal without harm. Apparently the eleven sufferers, all of whom took salt, not sugar, with their oatmeal, used one or more shakers rich in sodium nitrite and so fortified the dose they had already received in their oatmeal. These brief particulars of outbreaks make it clear that their origin has usually been one of two sources. One is due to the use of utensils, tanks, refrigerators or other articles coming in contact with food containing poisonous metals which only became dissolved when the food is acid or has very prolonged action. Often the article is sound originally but repaired with faulty material, such as refrigerator trays replated with cadmium, or when extensive quantities of lead were found in canned sardines and traced to the grills which had been badly tinned and gave up lead. T h e other main source is almost unbelievable carelessness. Quite poisonous chemicals such as those mentioned above are not labelled poisonous, are not artificially coloured .to give a warning sign and are left lying about to be mistaken for chemicals used for food and dumped in the kitchen or food store. Almost all these chemical outbreaks could have been prevented.
Positive Health for the Nation
" A Charter for Health,"* by a committee of the British Medical Association under the chairmanship of Sir John Boyd Orr, should be read as widely as possible by the public, by every politician and, we think, by the practitioners who may soon be part of the National Health Service. What is rather refreshing for a report from the B.M.A., there is n o mention of the current medico-political battle. T h e names of some of Sir John Boyd Orr's collaborators will indicate the quality of this report--Dame Janet Campbell, Professor Crew, Dr. G u y Damn, Dr. R. G. Gordon, Dr. Peter Macdonald, Professor J. i . Mackintosh, Dr. Arthur Massey, Professor R. M. F. Picken, Professor J. A. Ryle, Dr. C. O. Stallybrass, and Dr. Charles Hill as secretary, with other distinguished specialists and general practitioners. T h e report, published in attractive book form, is a straightforward statement of the real essentials of positive good health for the people ; it urges that, just as the Government adopted a wise food policy based on individual nutritional needs during the war, other factors in daily life and environment, e.g., housing, trade, agriculture, medical services or town planning, should be directed, as a national policy, towards the promotion of h u m a n welfare. T h e Committee's object is " to provide a ,comprehensive statement by doctors and other experts, of the basic factors of health, and of the basic human needs that must be satisfied if the highest possible level of physical and mental fitness throughout the community is to be reached and maintained." T h e report discusses, first, the role of medicine in the community, then, preventable disease and its causes, the importance of research, the family unit and the biological approach to physical and mental health through it, the design of the home, diet and its relation to income, occupational health and recreation, psychological influences, health education, statistics of sickness and mortality and the birth-rate. I n " H e a l t h of a Nation,"t Mr. Ritchie Calder, O.B.E., well known in scientific journalism, has produced an excellent picture of the present state of the communal and individual health, as a brief for discussion groups. Like the B.M.A. Committee, he points out that " n u t r i t i o n has been virtually written into the British Constitution " by the war, and emphasises the other basic needs of good environment. He goes on to describe medical practice as it is and as it will be under the National Health Service, and concludes by pointing out that, although the Bill provides for a medical service of a scope and competence which exists nowhere else in the world, personal health cannot be provided by legislation and the achievement of this remains with the health consciousness of every individual in the country. * Pp. 95. Illustrated. 6s. net. London. Allen and Unwin, 1946 Current Affairs, No. 3- PP. 2o. The Bureau of Cu/rent Affairs, Carnegie House, I17, Piccadilly, W.l.
PUBLIC HEALTH, July, i946
T H E ORGANISATION OF MEDICAL WORK* By J. J. BUCHAN, M.D., D.P.H., Barrister-at-Law,
Formerly Medical Officer of Health, City of Bradford I think I ought to make it clear at the very outset that I am only proposing to deal with the organisation of medical work as a means of improving the health of the community. T h e duty of preventing and combating disease is a very large one and there are engaged in it many and varied agencies, official and non-official, whose activities in any well-ordered system should be so correlated and linked u p that the best resutts are obtained from t h e work done. Nearly every profession is represented among the health workers of the country but the chief among them is the large personnel of the medical profession, a body of probably the most learned men in the country, who naturally must take the foremost place in the work. Besides them there are a large array of auxiliary health workers, sanitary, food and other health inspectors, health visitors, nurses, midwives and numerous kinds of technicians all of whom make valuable contributions to the betterment of health. T h e n there are institutions of all kinds engaged in the work, hospitals, large and small, voluntary and m u n i cipal, general and special, clinics of various kinds, health centres, educational and propaganda centres and numerous others, all of whom in varying degree and in different directions are helping forward the cause of health. Although it is a matter of personal moment to every citizen the people as a whole have not appreciated the importance of the duty of preventing and combating disease. T h e need of protection against simpler and more gross attacks is readily understood by them, b u t subtle and more deadly attacks of disease are still too often regarded as inevitable. Both centrally and locally our organisation f o r dealing with health and disease has been defective and a wide measure of reform has been long overdue. Unfortunately, centrally, health work has in the past occupied quite a minor place in the work of government. Its chief representative has never been regarded as a Minister of the highest rank so we have had a succession of distinguished and able men occupying the position few of whom have had sufficient time or opportunity to master the intricacies of the work. All this is no doubt an inherent defect in a democratic and Cabinet form of government, but this defect would have been of less moment if the Minister had had a representative council to advise him and to act under his instructions. T h e suggested Central Council of the National Health Service Bill falls very far short of such an executive council; the Minister will not generally be present to know and crossexamine the members as to the advice given, so that he will not be in a good position to come to his conclusions on the advice tendered. Nevertheless, we may take it that it is a step forward and will do some good. I n considering this subject it is perhaps useful to remind ourselves of quite simple things. Medicine, like all natural services, is not an exact one, it deals with living things and we have hardly begun to understand what life is. T h e knowledge and training of the medical profession makes it quite realistic in its approach to health and disease. While there is much that is unknown in the practice of medicine there is nothing known that is occult, knowledge has always been pooled and its daily progress recorded in a press that is open to a l l . T h e profession is therefore welt aware of most of the circumstances that .promote attacks of disease and it has a full knowledge available to it of what can be done to combat these attacks. Health and illness are attributes of life, and the preservation of the one, and the treatment of the other, are, for the most part, dependent on laws other than those made by Parliament, and we are all, even the greatest of us, but humble workers in a field on which the dictator has no part to play. T h e State has done much, and can do a great deal more, to improve the health of the people, but its success in the past should not permit us to forget that its capacity to do harm is infinitely greater than its power of doing good. But when so much is being said, and rightly said, of the rapid advances which are being made in curative medicine and surgery, it would ill become me, who has spent a lifetime as * Paper read to an Ordinary Meeting of the Society, London, May 24th, 1946.
I4I
rate of eight actual cases. These numbers are small, but it is one health visitor for every 200 babies and not 250 as stated noted that this finding is in agreement with the theory that in the broadsheet. Even so, such a standard is shockingly diphtheria cases treated with anti-toxin at an early stage of the low. Where the health visitor's duties are entirely confined disease do not result in lasting immunity for the patient; to children under the age of five years, then the standard therefore the best medical practice is to immunise the child should be not more than 100 babies per health visitor. One is glad to note that the fact is recognised that in modern u r b a n artificially within a few months after recovery." I n conclusion, while this survey is an important contribution areas with its frequent shifts of employment a n d the split up. to our knowledge concerning the incidence of diphtheria in a of families, it is difficult but not important to maintain the highly protected child population, it does not in many ways old conception of the family doctor. , One wonders what compare favourably with that admirable publication by the justification there is for a statement that most child Medical Researct{ Council, "The E15idemiology of Diphtheria health officers are trained in public health rather t h a n in the During the last Forty Years," by W. T . Russell, published in care of children or that their knowledge of nutrition is mostly 1943. T h e most important lesson to be learned from the survey inadequate. T h e recommendations made for the future is that complacency with regard to diphtheria immunisation structure of the child health service are along the lines already will probably result in an increased incidence of diphtheria. postulated by those immediately interested in the work. T h e Indeed, there is sopae evidence that in America sufficient value of the broadsheet is that these ideas should now reach stress has not been laid, up to the present, upon the necessity a wider public. of re-enforcing immunisation in infancy, with an additional dose of prophylactic or a Schick Test at school entrance. We Food Poisoning of Chemical Origin may go further than this in the future, and in order to avoid Food poisoning is always with us but the types prevailing an increased incidence among adolescents and the higher-age groups, endeavour to ascertain precisely by the Schick Test at any one time show considerable variation. T h e type now most commonly met with is undoubtedly that due to enterotheir level of immunity when leaving school. toxin produced under certain conditions by some types of staphylococci, and we have had a great many such outbreaks The Child Health Services right through the war. Salmonella outbreaks also have T h e broadsheet recently issued by P.E.P. on Child Health occurred but during recent years have been comparatively and Nutrition comes very appropriately at the present time, less numerous. Side by side, and perhaps more frequently coinciding as it does with the publication of the National of late, there has been a n u m b e r of food poisoning outbreaks Health Service Bill. I n the first few paragraphs it makes a in which the poisoning is due to comparatively simple Chemical very- pertinent comment that the Bill still departmentalises bodies. Those until recently were mainly arsenical poisoning, medical work between hospitals and general medical practi- some zinc poisoning from action of acid foods in zinc retainers, tioners and the local authorities in a way which cuts across antimony poisoning, usually with lemonade as the vehicle the fundamental unit of maternity services, which are essentially made in enamelled pails which contained antimony in the health rather than sickness services. However, as the broad- enamel, occasional cases of lead poisoning from food; but sheet quite truly says, it is probably the best that can be never poisoning from tin, a remarkable testimony to the nondevised without a systematic overhaul of the structural toxic properties of tin. T h e deaths from di-ehlor-cresol and other bodies found as adulterants in alcoholic drinks have machinery and functions of local government. A finger is also put on the very great weakness of the Bill been very numerous. D u r i n g ' t h e last year or so more varied types of chemical in that many of the authorities who will have child welfare duties delegated to them will lose all responsibility, for maternal food poisoning have been reported. Chiefly in America quite care. This separation of mother and child and the apparent a number of cases of cadmium poisoning have occurred. failure to recognise that they are one unit is to be deplored. T h e i r origins have all been very similar, the cadmium gaining If a great deal of damage is not to be done to the fine work access to the food from refrigerators, of which the trays or already achieved by the maternity and child welfare services other parts were plated with materials largely 'composed of then miracles of co-operation and administration will have to cadmium. Cases of fluoride poisoning have been reported be performed. T h e broadsheet does well to stress at this due to sodium fluoride (an insecticide) being used mistakenly time that the primary responsibility for bringing up healthy for table salt or baking powder. In the B.M.~. of December children must rest on the wisdom and care of their parents 8th, 1945, two outbreaks are described, the vehicles respecand that in a fully healthy society this can be achieved. I n a tively being marmalade tart and treacle tart. Both were due r6sum6 of the present child health services it is pointed out to barium carbonate, which was being used as a rat poison that even in those cases where child welfare and school health and a sack of it was placed in error in the flour store and so services were under the same authority they were often poorly became used in the pastry of the tarts. In the Quarterly co-ordinated while the separation of both these services from Bulletin of the City of New York Health Department for December, 1945, three chemical outbreaks in 1944 are the domiciliary" and institutional services could hardly b e wider. At present local authorities possess wide powers but described. I n the first about 30 workers in a war cable few definite duties, with the result that in some areas the plant complained of gastro-intestinal and nervous symptoms services are excellent but in others the standard of facilities over a period of some two weeks. T h e y all worked on the provided is low. Proper food is the greatest single factor in third floor and in the water cooler for this floor were found human health, and it is stressed that food education should crystals of potassium thiocyanate; calculations showed that a glass of water would contain about 0.48 gramme of potassium conrinue'to be a feature of our national policy. It is pointed out that continuity of medical care for each thiocyanate, a toxic dose. How the thiocyanate gained access individual Child is the ideal for a first-class service but that could not be ascertained. T h e second involved four girl this does not necessarily mean that the same doctor or the workers who suffered from nausea and vomiting five to 15 same health visitor should be concerned with the same child minutes after taking a soft drink from a local dispensing however desirable that may be. There must be a service machine. T h e water tank was co~aper-lined and through a which operates as a unit whatever the administrative back- defective valve carbonic acid gas gained access to the water ground. T h e training and qualifications of the future health department and dissolved as much as 85 parts per million visitor are discussed and the view is taken that health visitors of copper, making a glass of this water capable of causing should be confined to work directly concerned with the welfare toxic symptoms. The third outbreak involved eleven old men of children. It is suggested that a new type of visitor should who were admitted to hospital suffering from cyanosis and undertake the more general service of advice to households shock; one died. All eleven had breakfast that morning in envisaged in the Bill. There are many arguments for and the same cafeteria. T h e symptoms were due to sodium nitrite against this. What is quite certain is that if the duties of eaten partly in oatmeal and partly derived from salt shakers. the health visitor are to be greatly extended at least four times A can of salt which actually was curing salt and contained the number of health visitors will be required. T h e standard 925/o of sodium nitrite was on the shelf in the kitchen along set in war-time by the Ministers of Health and Labour was with one of ordinary salt, and the cook used it to add to the
142 oatmeal. T h e salt shakers contained varying amounts of sodium nitrite, some having only faint traces, others as high as 0.187%. Some 125 people were served in the cafeteria and many took oatmeal without harm. Apparently the eleven sufferers, all of whom took salt, not sugar, with their oatmeal, used one or more shakers rich in sodium nitrite and so fortified the dose they had already received in their oatmeal. These brief particulars of outbreaks make it clear that their origin has usually been one of two sources. One is due to the use of utensils, tanks, refrigerators or other articles coming in contact with food containing poisonous metals which only became dissolved when the food is acid or has very prolonged action. Often the article is sound originally but repaired with faulty material, such as refrigerator trays replated with cadmium, or when extensive quantities of lead were found in canned sardines and traced to the grills which had been badly tinned and gave up lead. T h e other main source is almost unbelievable carelessness. Quite poisonous chemicals such as those mentioned above are not labelled poisonous, are not artificially coloured .to give a warning sign and are left lying about to be mistaken for chemicals used for food and dumped in the kitchen or food store. Almost all these chemical outbreaks could have been prevented.
Positive Health for the Nation
" A Charter for Health,"* by a committee of the British Medical Association under the chairmanship of Sir John Boyd Orr, should be read as widely as possible by the public, by every politician and, we think, by the practitioners who may soon be part of the National Health Service. What is rather refreshing for a report from the B.M.A., there is n o mention of the current medico-political battle. T h e names of some of Sir John Boyd Orr's collaborators will indicate the quality of this report--Dame Janet Campbell, Professor Crew, Dr. G u y Damn, Dr. R. G. Gordon, Dr. Peter Macdonald, Professor J. i . Mackintosh, Dr. Arthur Massey, Professor R. M. F. Picken, Professor J. A. Ryle, Dr. C. O. Stallybrass, and Dr. Charles Hill as secretary, with other distinguished specialists and general practitioners. T h e report, published in attractive book form, is a straightforward statement of the real essentials of positive good health for the people ; it urges that, just as the Government adopted a wise food policy based on individual nutritional needs during the war, other factors in daily life and environment, e.g., housing, trade, agriculture, medical services or town planning, should be directed, as a national policy, towards the promotion of h u m a n welfare. T h e Committee's object is " to provide a ,comprehensive statement by doctors and other experts, of the basic factors of health, and of the basic human needs that must be satisfied if the highest possible level of physical and mental fitness throughout the community is to be reached and maintained." T h e report discusses, first, the role of medicine in the community, then, preventable disease and its causes, the importance of research, the family unit and the biological approach to physical and mental health through it, the design of the home, diet and its relation to income, occupational health and recreation, psychological influences, health education, statistics of sickness and mortality and the birth-rate. I n " H e a l t h of a Nation,"t Mr. Ritchie Calder, O.B.E., well known in scientific journalism, has produced an excellent picture of the present state of the communal and individual health, as a brief for discussion groups. Like the B.M.A. Committee, he points out that " n u t r i t i o n has been virtually written into the British Constitution " by the war, and emphasises the other basic needs of good environment. He goes on to describe medical practice as it is and as it will be under the National Health Service, and concludes by pointing out that, although the Bill provides for a medical service of a scope and competence which exists nowhere else in the world, personal health cannot be provided by legislation and the achievement of this remains with the health consciousness of every individual in the country. * Pp. 95. Illustrated. 6s. net. London. Allen and Unwin, 1946 Current Affairs, No. 3- PP. 2o. The Bureau of Cu/rent Affairs, Carnegie House, I17, Piccadilly, W.l.
PUBLIC HEALTH, July, i946
T H E ORGANISATION OF MEDICAL WORK* By J. J. BUCHAN, M.D., D.P.H., Barrister-at-Law,
Formerly Medical Officer of Health, City of Bradford I think I ought to make it clear at the very outset that I am only proposing to deal with the organisation of medical work as a means of improving the health of the community. T h e duty of preventing and combating disease is a very large one and there are engaged in it many and varied agencies, official and non-official, whose activities in any well-ordered system should be so correlated and linked u p that the best resutts are obtained from t h e work done. Nearly every profession is represented among the health workers of the country but the chief among them is the large personnel of the medical profession, a body of probably the most learned men in the country, who naturally must take the foremost place in the work. Besides them there are a large array of auxiliary health workers, sanitary, food and other health inspectors, health visitors, nurses, midwives and numerous kinds of technicians all of whom make valuable contributions to the betterment of health. T h e n there are institutions of all kinds engaged in the work, hospitals, large and small, voluntary and m u n i cipal, general and special, clinics of various kinds, health centres, educational and propaganda centres and numerous others, all of whom in varying degree and in different directions are helping forward the cause of health. Although it is a matter of personal moment to every citizen the people as a whole have not appreciated the importance of the duty of preventing and combating disease. T h e need of protection against simpler and more gross attacks is readily understood by them, b u t subtle and more deadly attacks of disease are still too often regarded as inevitable. Both centrally and locally our organisation f o r dealing with health and disease has been defective and a wide measure of reform has been long overdue. Unfortunately, centrally, health work has in the past occupied quite a minor place in the work of government. Its chief representative has never been regarded as a Minister of the highest rank so we have had a succession of distinguished and able men occupying the position few of whom have had sufficient time or opportunity to master the intricacies of the work. All this is no doubt an inherent defect in a democratic and Cabinet form of government, but this defect would have been of less moment if the Minister had had a representative council to advise him and to act under his instructions. T h e suggested Central Council of the National Health Service Bill falls very far short of such an executive council; the Minister will not generally be present to know and crossexamine the members as to the advice given, so that he will not be in a good position to come to his conclusions on the advice tendered. Nevertheless, we may take it that it is a step forward and will do some good. I n considering this subject it is perhaps useful to remind ourselves of quite simple things. Medicine, like all natural services, is not an exact one, it deals with living things and we have hardly begun to understand what life is. T h e knowledge and training of the medical profession makes it quite realistic in its approach to health and disease. While there is much that is unknown in the practice of medicine there is nothing known that is occult, knowledge has always been pooled and its daily progress recorded in a press that is open to a l l . T h e profession is therefore welt aware of most of the circumstances that .promote attacks of disease and it has a full knowledge available to it of what can be done to combat these attacks. Health and illness are attributes of life, and the preservation of the one, and the treatment of the other, are, for the most part, dependent on laws other than those made by Parliament, and we are all, even the greatest of us, but humble workers in a field on which the dictator has no part to play. T h e State has done much, and can do a great deal more, to improve the health of the people, but its success in the past should not permit us to forget that its capacity to do harm is infinitely greater than its power of doing good. But when so much is being said, and rightly said, of the rapid advances which are being made in curative medicine and surgery, it would ill become me, who has spent a lifetime as * Paper read to an Ordinary Meeting of the Society, London, May 24th, 1946.