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REFORM OF THE POOR-LAW: THEAPPROACHING OPPORTUNITY.

REFORM OF THE POOR-LAW.-PURE MILK.

THE LANCET.

LONDON: SATURDAY, JUNE 27, 1925.

IT is not, we hope, merely fantastic, in the twenty-fifth year of the century, to treat the question ofhealth progress in quarter-century periods. Thelast quarter of the nineteenth century witnessedthat remarkable advance in sanitary science and thattremendous development in environmental hygienewhich owed its inspiration to the great reformers ofthe mid-Victorian era, and which followed uponthe recommendations of the Royal Sanitary Com-mission in 1871. In the succeeding period of 25

years we have seen a quickening of the publicconscience in regard to communal suffering anddistress which has found its expression in legislativeand administrative measures directed to the ameliora-tion’of the lot of the individual. Those hard-workedwords " overlapping " and " coordination " havebeen doing good service in recent years and theyhave a long period of activity in front of them.It is, we suppose, common ground that in the healthlegislation of the two quarter-century periods towhich we have referred there is no clear evidence of

proceeding according to plan. Here some new functionhas been tacked on to the work of an existingauthority; there a new authority created and setworking on independent lines. Where provision hasbeen made, as in the National Health InsuranceAct of 1911, for cooperation with existing bodies,it has been largely a dead letter. And so, on thethreshold of another 25-year period, stands Mr.NEVILLE CHAMBERLAIN facing a wonderful opportunity.With the impatience of those who will question theneed for the elapse of so long a time before a properdevelopment of the plans of public health are laiddown definitely and who would like to put things right Ito-day, we have much sympathy. But to the I

discerning observer it is clear that over such a regionas there is to travel rapidity of movement is impossible.This third period of 25 years, we venture to say, is tosee the plans prepared for statesmanlike structure ofpublic health administration, the foundations laidbroad and deep, and maybe the building itself erected,equipped, and fully functioning.

In support of the long view in these matterswe may reflect that it was so far away as 1871 that the

Royal Sanitary Commission recommended that thereshould be one local authority for all public healthpurposes in every place, so that no area shouldbe without an authority or have more than one ;It was in 1909 that the Poor-law Commission madethose recommendations, to which successive Ministershave given their blessing, for the abolition of boardsof guardians, whose functions were referred to bythe Maclean Committee in 1917 as involving the largestand the most intractable case of overlapping withother authorities. Mr. NEVILLE CHAMBERLAIN hasrecently reaffirmed his intention of tackling theproblem of the reform of the Poor-law. He would,we expect, be the first to disavow any suggestion- :that the health functions of the guardians are being

inefficiently performed. It is generally recognisedthat a large and increasing number of our Poor-lawinfirmaries are in a position to place at the disposalof the poor and destitute members of the communityprofessional care and equipment beyond the reachof a large majority of the members of the community.But the position is that beds in Poor-law infirmariesto the number of 100,000 are, to a large extent,not used to the best advantage or not used at all,while there is a deplorable shortage of beds in ourvoluntary hospitals. Sentimental objections to theword Poor-law, and recollections of what that wordhas formerly conveyed, should not blind us to thesethings. In clearing the ground for the development ofa scheme of public health services under one localauthority we have in the Poor-law an administeringsystem, levying enormous public funds for thedischarge of its functions, which arise from theexistence of disease and distress, yet having no dutiesor powers in respect of their prevention. To say thisis to say how much of the old order must be kept, buthow much it needs before it can be kept usefully.We do not detail any instances of overlapping of

public medical services, for they are so well known.The Poor-law question in any case is the most seriousproposition, and it may be assumed that, in his

proposals for the coordination of various publichealth services which will be discussed with localauthorities, including the boards of guardians them-selves-and, we have no doubt, the representatives ofthe medical profession-Mr. NEVILLE CHAMBERLAINwill deal thoroughly and courageously with it. Sincethe Ministry of Health was created as the first stepin the direction of placing all health services underone control, Ministers of Health have come and gonewith rapidity. Mr. CHAMBERLAIN has before him, asfar as one can foretell, a long period of office. He is,we believe, a man of untiring industry, and if he isapproaching in a broad spirit the great and intricateproblems, he will have accepted a splendid responsi-bility for developing a new era of public healthadministration. The problems, as we have said, do notlend themselves to rapidity of solution. Questions ofvaluation and of reconstruction of areas necessitateconsultation with large groups of interests and withmany types of experience, and perhaps the overthrowof groups and individuals who will die hard. Theopportunity approaches for big work in a big cause.

THE PURSUIT OF PURE MILK.MILK is the most important food available to

mankind. Every medical practitioner is aware of itsvalue, but his desire to see it more fully utilised isfrustrated by his knowledge of the unsatisfactoryconditions under which, only too frequently, it is

placed upon the market. Few foods have receivedmore consideration, and for few have more strenuoussteps been made to obtain a better product. In aseries of articles, completed in this issue, Dr.W. G. SAVAGE discusses the problem and why theseefforts have not been more successful. One cardinalfactor in the position, is that the supply of milk is amatter of great importance to the agriculturist, andagricultural interests have often been exerted tofrustrate efforts to provide efficient control. Thegreatest contamination of milk takes place at the cow-sheds which are mostly in rural areas, and the controlover production is placed and retained in the hands ofbodies composed almost entirely of farmers or personsdirectly in business relationship with farmers andmilk producers. The control over meat is not left in

1352 PROPHYLACTIC VACCINATION AGAINST TUBERCULOSIS.

the hands of butchers and meat purveyors. The1922 Milk Act added extensively to the control overpurveyors of milk, but avoided touching milk produc-tion. It is well known that the powers of supervisionover milk production are very inadequate, but it willcome as a surprise to many medical men that it is notillegal for a milker with unwashed hands and dirtyclothes to milk manure-plastered cows with dirtyudders into an open pail in a dusty hay-laden shed,and for that bacteria-laden milk to be sent longdistances without any attempts at cooling. Controlis also very ineffective as regards the prevention ofacute infectious disease spread by milk or the elimina-tion of the danger of the transmission of bovinetuberculosis from cows suffering from that disease.

. An important point stressed by Dr. SAVAGE is theclose relationship between the quality of milk suppliedand the demands of the consumer. At present theaverage producer obtains the same price for his milk,clean or dirty; why then should he go to the trouble andexpense of providing a cleaner milk which is of nocommercial value to him and which by law he is notcompelled to provide ? This fact suggests that onefundamental condition for obtaining a clean pure milk-supply is to create a demand for it on the part of theconsumer. Clean pure milk must be made a businessproposition, and Dr. SAVAGE indicates ways in whichthis can be done. Incidentally he points out that themedical profession is not pulling its full weight in thismatter, both by failing to support actively milkproducers and distributors who do supply clean milk,and by neglecting to use influence to see that hospitalsand other institutions, in their contracts for milk,specify milk of high bacterial purity. An educatedpublic opinion on this subject will make it mucheasier to ensure that supervision over milk produc-tion and distribution will be effective ; the presentcontrol is farcical. The existing system of certain

special grades of milk is admirable from this point ofview as an educative influence, since their existencebrings home to the consumer that milk is not auniform article, one and indivisible, but is of veryvarying quality and purity. Apart from its educativeeffect, these grades touch but the fringe of the problem,and it is not very likely that they will extend to morethan a small minority of producers. But the risk of theacquisition of tuberculosis from milk is a very real one;and a factor which is the cause of over 3000 deaths ayear, on a very conservative estimate, and of a seriousmass of preventable disease calls aloud for remedy.Dr. SAVAGE gives no short cut in regard to the difficultproblem of the prevention of bovine tuberculosis, anddoes not discuss the subject in detail. Experienceelsewhere shows, however, that it is possible to buildup and maintain herds of non-tuberculous cows, whilethe elimination of cows actively disseminating thebacilli is a valuable auxiliary procedure. The develop-ment of orthopeedic schemes for treating tuberculousand other cripples will probably give a considerablestimulus to the prevention of bovine tuberculosis, as itwill become increasingly recognised that it is folly tospend huge sums on the treatment of tuberculouscripples without at the same time actively taking stepsto prevent their manufacture.We would direct attention to Dr. SAVAGE’S remarks

on pasteurisation, since there is so much confused

thinking on the subject. The basal fact is that at thepresent time the bulk of the milk consumed in thelarge towns is pasteurised by processes which are

uncontrolled as regards the temperatures reached orthe time the milk is held at a high temperature, andthat such milk is sold as fresh milk. Some of it ispasteurised more than once. Reliable data are lacking

to enable an opinion to be given as to whether suchuncontrolled pasteurisation does or does not damagethe nutritive qualities of the milk. It is a tradepractice to enable initially dirty milk to survive as acommercial product. Such treatment is entirelydifferent from controlled pasteurisation and distinctfrom the question whether the latter is in itselfa valuable and satisfactory solution of the milk

problem. In either case it is a substitution of heattreatment for clean production. A point of interest isas to whether conditions are improving. Dr. SAVAGE,from his unrivalled experience, considers that materialimprovements have taken place in the handling of milkafter production, but that up to two or three yearsago there was little evidence of betterment in thebacterial contamination at the cowsheds. During thelast few years definite progress has been made,especially in regard to the sowing of the seeds ofdissatisfaction with existing methods in the mindsboth of the producers and of the consumers, and in thebetter goodwill and understanding of the problemshown all round. The Milk and Dairies (Consolidation)Act, 1915, has never been put in force, but is due tocome into operation on Sept. lst next, and the Ministerof Health has stated that its operation will not befurther postponed. Much of its value will depend uponthe regulations made by the Ministry of Health underSection 1 of the Act, and these have to be framedwith the concurrence of the Board of Agriculture.. TheAct has many defects, but, if efficient regulations areallowed to be made, it should improve markedly thelegal control over milk production and distribution.For its efficient working it will need the support of allthose who care for clean food. The medical professionbelieves in clean milk, and considers the consumptionof it per head to be deplorably low. It will give itssupport to any reasonable measures to give us a pureclean milk-supply, and to remove what remains atpresent a serious blot upon the administration ofpublic health in this country.

PROPHYLACTIC VACCINATION AGAINSTTUBERCULOSIS.

VACCINATION against tuberculosis shows signs ofrevival in a new form. Since the early days of thetuberculin era vaccines in one form or another havenever entirely failed to excite interest and experimentin one quarter or another, and it would probably beno exaggeration to say that more time and efforthas been spent on the tuberculosis vaccine than onany other form of bacteriological research. Recentyears have seen a further application of these

researches in one particular direction-viz., the

prophylactic vaccine. Old and new tuberculinhave both been used in this way for many years,but the efforts put forth have been, on the whole,sporadic and the results equivocal. Shortly afterthe war popular excitement was aroused in Spain-it seems the fate of tuberculosis remedies to createunbalanced optimism-by the production of theFerran vaccine. This vaccine was not derived fromthe tubercle bacillus itself, but from an organismof the B. coli group, from which it was claimedB. tuberculosis was descended. Dr. J. CHABÁS, ina recent number of the Revista de Hygiene y de T1lber-culosis (Valencia) has revived this subject, whilstattention has also been called to it in South America.

1 Under Section 14 of the Milk and Dairies (Amendment)Act, 1922, the Scottish Board of Health have just issued anOrder, under which the Milk and Dairies (Scotland) Act, 1914,will also come into operation on Sept. 1st, 1925.