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The total number of deaths in England and Wales during 1904 was 549,393. Of this number 137,490—practically one-fourth of the whole—were of children under one year. Further examination of these figures shows that half of the children died from preventable diseases, among which diarrhoea was accountable for over 28,000 deaths. Such is the lamentable story to be gathered from statistics, which further inform us that efforts are being made by leaflets, lady health-visitors, and the supervision of the milk-supply to remove or remedy the ignorance and prejudice which have been responsible for the greater portion of this death-roll.

This is the powerful indictment which we have to lay against the present supply and handling of milk—that it is responsible for an enormous amount of preventable mortality, and what makes the matter so deplorable is that it almost entirely arises from a want of sufficient knowledge as to the proper treatment of the matter on the part of the consumer. Before we can hope for the slightest improvement in the present rate of infant mortality we shall have to inculcate a more careful adherence to sanitary methods on the part both of the producer and consumer. It may as well be stated at once that, whatever evils may be produced by the consumption by infants of milk in too great quantities or at improper temperatures, the main cause of the loss of so large a number of young lives is—dirt. Let it be written in letters of flame if possible—dirt. It is not necessarily solid, tangible matter, but of a kind far more dangerous, because so much more insidious, that sort of defilement which creeps into milk in the form of disease-germs or dust, owing to a want of proper protection against such contamination.

A highly interesting and important paper was read upon this subject before the British Medical Association at Oxford in July,

1904, by Dr. Newman, the Medical Officer of Health for Finsbury. In this paper he drew attention to the number of diseases which might be conveyed through the medium of milk, and mentioned several outbreaks which had been traced without difficulty to this source. Among such diseases were mentioned typhoid fever, scarlet fever, diphtheria, sore throat, epidemic diarrhoea, and tuberculosis—surely an imposing array. If it were proved, as there is little doubt it can be, that only one or two of these diseases are commonly conveyed through milk, very good ground would be presented for examining minutely the present condition of the milk-supply, and for trying to find some way in which the lamentable loss of infant life might be prevented.

In order to understand properly the present state of affairs, and to see how it has arisen that the danger has only lately become so startlingly prominent, it will be necessary to take a short survey of the milk trade during the last half-century. The first thing which we notice on taking such a survey is the change in distribution of the population. Great as have been the effects of this alteration in many other directions, it can be maintained that these effects have been felt to their fullest extent in the matter of milk and its supply. We have heard a great deal lately about physical deterioration—it has even been thought worthy of a commission of enquiry—but it would seem as if among all the agencies at work which tend to produce such deterioration none had a more potent influence than the milk-supply. The connection may at first sight appear to be a little far-fetched, but it is not so in reality.

A century ago the population of England and Wales was nearly nine millions, of which total about sixteen per cent, lived in the large towns ; in 1904 the population was thirty-three millions, of whom nearly sixty per cent, lived in the large towns. This change is the immediate result of the downfall of agriculture, with the consequent inability on the part of the land to support the large number of labourers and their families who formerly obtained a living from it. The great fall in the price of cereals was the immediate cause of a large quantity of land going out of cultivation, and being replaced by grass ; and this change led to the rural exodus, with its consequent disturbance of the distribution of population. Every one of those families which formerly lived on the land had been large consumers of milk ; milk and bread had been their staple foods. The exodus to the towns altered all this, and not only directly affected those who left the country, but produced its indirect effect upon those who remained behind. The reason was as follows.

In olden days the greater part of the milk produced was used in the districts which produced it, with the result that it was consumed at once and before it had time to deteriorate. This fact is liable to be overlooked by those who argue that milk is the same as it always was, and that what was good enough to produce the sturdy generations of yeomen of earlier days is good enough for our generation. Those yeomen drank fresh milk ; we do not. The great increase of population in the towns gave rise to a large demand for milk, which was supplied from the country districts. At first dairymen in the neighbourhood of the towns were capable of meeting all the calls made upon them, but little by little other districts further away from the large centres were brought under contribution, until to-day we find a large quantity of milk coming from places a hundred or even two hundred miles away. The result is, of course, a journey of many hours’ duration before the milk reaches the consumer. This, even with every precaution, would tend to render the article inferior as a food, and, in the case of the milk being impure, would render it absolutely poisonous on reaching its destination. This is the vital difference in the position to-day. Absolute cleanliness was not so essential when the milk was consumed at the source, and before a sufficient time had elapsed to allow the dirt and bacteria to do their work. But to-day milk of the same quality, forced to undergo a long journey and to become subjected to the most undesirable changes, has produced results which should have been foreseen, which are still preventable, and which must be remedied if the present physical deterioration of the race is to be arrested.

Undoubtedly the most important phase of the milk question is in connection with the feeding of infants. Very little can be done to raise the physical standard of the present generation, therefore we must turn ail our attention to that which is just entering upon life. All our leading medical men have urged again and again that nothing can take the place of natural rearing, but there are, of course, cases in which a substitute must be found. So soon as the ordinary milk of the cow is used we are confronted with complications, and of these the two most difficult to deal with are malnutrition and diarrhoea. The latter alone concerns us

No. 4—vol. 1 To here, for in the majority of cases it is the direct result either of improper feeding or unwholesome milk. Space will not permit me to enter upon a discussion of the methods of feeding in vogue, nor is it necessary. There are many excellent works on the subject in which the matter is treated in full. But it is desirable to point out, and to urge with every argument at my command, that a great many of the cases of illness are the result of impure milk, or of milk which has undergone fermentation. Another very common cause of it is the use of unclean receptacles and bottles; I will refer to this presently when I come to deal with methods of prevention.

So soon as a little light began to dawn on the subject (and chiefly impelled probably by the fact that a large quantity of milk was returned as unfit for use) the milk-producer set himself to discover some method by which his milk might be enabled to stand the necessary railway journey, and arrive at its destination before any undesirable changes could take place, or, if they had taken place meanwhile, before they could be noticed. This led to the practice of introducing “preservatives” into milk, the effect of which was to delay fermentation. The remedy was worse than the disease. A report on the subject, signed by Dr. Bernard Dyer, was presented to the Essex County Council, and from it I take the following pregnant sentences:

But a short time since a sample of milk drawn under the Sale of Food and Drugs Act in the county was found to contain as much as 24 grains of boric acid per pint, and, although such heavy quantities as this are happily of exceptional occurrence, a considerable number of the samples of milk taken under the Sale of Food and Drugs Act within the county are found to contain the preservatives in varying quantities. We are all distinctly of opinion that milk containing boric acid, formalin, or any other preservative, is not to be regarded as of the nature, substance, and quality of genuine milk, and that cases of its sale should be dealt with accordingly.

This extract, to which any number of similar instances might be added, gives us some idea of the prevalence of preservatives in milk. The report objects to the use of preservatives upon the ground that milk containing them is not of the nature of genuine milk. While I fully agree with this opinion, I have other reasons equally cogent against the use of preservatives. Firstly, there is no limit to their employment, so that by the time the milk is delivered it may be extremely poisonous. The producer puts in a small quantity of preservative before the milk starts on its journey; the purveyor in the town adds a small quantity; and, finally, the retailer follows suit. Imagine the state of the milk when it reaches its destination!

But there is a second objection to the use of preservatives, which seems to me even stronger. It is this : instead of attacking the evil—the impurity of the milk—at its source, the use of preservatives enables the seller, by a dangerous but effective expedient, to conceal its deficiencies. Therefore, even if there were no other radical objections to the use of preservatives, there would always be this one. No advance could ever be made in any direction unless the forces which were working in opposition were first brought to light and then neutralised. And as I laid it down at the beginning that dirt—in some form or other, whether it be labelled as dust, bacteria, or preservative—is the giant in the path of progress, so I contend that everything which assists in the concealment of the offence is objectionable and should be forbidden by law.

The objections to the use of preservatives led to the system of sterilisation. This consisted merely in heating the milk to a certain temperature at which it was found that the majority of disease-producing germs were destroyed. The idea was a clever one, and could probably be employed with great advantage in the case of any other substance but milk. You cannot heat milk to a high temperature without radically affecting its composition. Moreover, there is very good reason to believe that there are certain ferments present in milk, just as there are in some other foods, which are destroyed by subjection to unusual heat. Therefore you are faced with the problem, that though by boiling the milk you may kill bacteria, you are at the same time injuring it as a food. The subject has been discussed by Dr. V. Vincent. In The Nutrition of the Infant he says:

As the use of boiled or sterilised milk has become more general, the results have been far from what was expected, and the injurious effects are being frequently demonstrated. . . . The exposure of milk to heat is attended with various alterations in the character of the milk, and as these are of the first importance in reference to infant feeding, the character of these reactions must be recognised. Moreover, no amount of pasteurisation or sterilisation can convert an unclean milk into a clean one. These processes have no action on the toxins already formed in milk by the action of bacteria. Boiling the milk when received in the house may kill the micro-organisms, but it cannot remove these poisons. . . . The author has seen many cases of gastric and intestinal disturbance arising from the toxins present in pasteurised and sterilised milk. . . . But the most serious objection to sterilisation is that it irretrievably injures the food of the infant, definitely destroying vital elements essential to nutrition.

There could be no dearer and more forcible expression of opinion on the disadvantages of sterilisation than this by one of our leading authorities on the feeding of infants.

I cannot refrain from referring to an article by Dr. Ostertag which appeared in the Danish monthly Review for Veterinary Surgeons for August last year. Dr. Ostertag observes that in the course of the last fifteen years it has been repeatedly proposed in Germany that a law should be passed that all milk should be pasteurised. Against this proposal it was at first objected that it would be impossible to carry it out, and also that there were other objections on sanitary grounds. It is now believed that if milk is pasteurised its condition is so altered that instead of being an article of nourishment it is a source of danger; and Dr. Ostertag says that he does not believe there exists at the present time any expert who will recommend the heating of all milk offered for sale, and that, on the contrary, efforts are directed towards producing the milk under such conditions that it may be consumed raw even by infants.

And now let us pause for a moment to take stock of the position. While it has been granted that milk and its treatment need alteration, objection has been taken to the use of preservatives and also to the practice of sterilisation. We would seem to be in a very bad way. So impressed have some of our local authorities been with the urgency of the question that they have taken the milk-supply of their particular towns into their own hands. They have opened what are known as “milk depots,” where milk suitable for feeding children and invalids is dispensed at a moderate price. But the weakness of this system became speedily apparent. The milk was handled in excellent fashion after it had reached the depot, but no one could tell what had happened to it befon that time. Therefore a demand was made that the local authority should also take upon itself the production of milk, in order that it might be able to supervise the whole process from start to finish. Thus we find municipal dairies in process of establishment, and I cannot but think that in progress of time force of circumstances will compel these municipalities to extend this department still further, until at length they have completely ousted the individual dairy-firmer. This is a very strong objection to a municipal milk-supply. It cannot be right that a whole body of men should be deprived of their livelihood until every other method has been tried and has failed. Moreover, it is almost a necessity that these municipal dairies should be located in the town itself, and it cannot be expected that milk produced in such surroundings can ever be at all comparable with that produced from cows of the same class in the country.

But I have not come thus far, after upsetting every expedient hitherto devised, without any intention of suggesting some alternative. There is only one remedy for the present state of things, and this consists in retracing our steps, giving up these false ideas as regards preservatives and sterilisation, and simply insisting upon adherence to a system which, if it had been formerly maintained, would have rendered all such expedients unnecessary—greater cleanliness, and cleanliness not only in the transit of milk to its destination and in its subsequent management, but at the very source, before, at, and after milking. And as example is better than precept I propose to give as briefly as possible an account of the whole process from start to finish, and to show what precautions must be observed if pure, wholesome milk is to be obtained.

Provision must be made for a proper supply long before the first drop of milk has made its appearance. Only healthy cows should be admitted into the milking herd. They should be examined periodically, and any which show the smallest signs of weakness or disease should be dismissed from the herd. The milkers should themselves be healthy, should be clean in person, and should be instructed in the rudiments of hygiene. Before a drop is drawn the flanks and udder of every cow should be wiped with a damp cloth, so that particles of dirt or hairs may be prevented from falling into the milk. If possible a milk-pail should be used fitted with a gauze-wire strainer. One dairy in Denmark goes so far as to provide pails with a double bottom, in the lower part of which a mixture of ice and salt is placed in order to cool the milk immediately it is drawn.

The first few streams from each teat should be thrown away. The bacteria found in milk are mostly congregated near the opening of each teat, and therefore are washed out by the first milk drawn, and should never be allowed entrance into the milk-pail. Milking should be carried out quietly, quickly, and thoroughly, for only by this means will all the cream or fat in the milk be extracted. The last half-gallon contains the greater proportion of the fat, and therefore it will be understood how important it is that every drop of milk should be drawn if its quality is to be of the best. So soon as milking is finished the yield of each cow should be weighed, and the milk must then be taken to the refrigerator to be cooled to as low a temperature as possible. There is an innovation lately introduced which should prove of very great benefit to dairy-farmers, by which milk can be scalded and cooled by the same machine at one operation. The milk is first passed over the upper portion of the machine, by which it becomes heated to about 160 degs., whence it passes to the refrigerator or brining machine and is cooled to 40-45 degs. If these two processes are properly and thoroughly carried out the milk is enabled to undergo a long journey and to arrive quite sweet at its destination.

It is desirable that whenever possible the cows should be milked in the open air. However clean and well-aired the cow-house may be it can never approximate to the freshness and purity of the open air. The greatest amount of freedom possible is also desirable for the cows themselves, for not only does this tend to produce a sound digestion and therefore milk of better quality, but where there is any tendency to tuberculosis, as is unfortunately the case with a large percentage of dairy cattle, pure air and sunlight assist in keeping this tendency in abeyance.

All utensils employed in the handling and distribution of milk should be kept absolutely clean. This should not be taken to mean that they are to be rinsed out with cold water ; the process should be taken a step further. The utensil should be first rinsed in cold, then washed in boiling water, and, lastly, rinsed in cold water once more. Unless cold water is used in the first case the milk adhering to the sides of the vessel would be coagulated by the hot water and the utensil could not be properly cleansed. All babies’ bottles, mouthpieces, and tubes must undergo a similar treatment, and if they can be scalded in steam so much the better. Long tubes or corrugated mouthpieces are objectionable, for they cannot fail to harbour particles of stale milk, which, on the bottle being refilled for another meal, immediately affect the freshness of the new liquid. Lastly, the cans used for transporting the milk by rail should be locked, so that the contents may not be tampered with in transit, and the truck in which the cans are carried should be in the nature of a cold chamber.

If these simple but necessary points are properly attended to nearly all that is humanly possible will have been done to render milk free from disease germs, and capable after a long journey of arriving fresh and wholesome at its destination. Once there, it should be treated with equal care. It should not be permitted to stand in an open vessel upon the shop counter, exposed not only to dust and flies, but also to the countless swarms of bacteria with which the air is continually permeated ; nor should it stand in some kitchen or pantry exposed to air at a high temperature. Proper cool chambers should be provided in all cases, and the receptacles for holding the supply should possess proper covers of fine gauze-wire or muslin. When the milk is in bottles there is no better form of stopper than a plug of cotton-wool, as this prevents the entrance of all germs.

Once let us obtain clean milk, so that we may use it in its pure state for infants and invalids without fear of any bad results, and the problem is solved. There is not the slightest doubt in my mind, after a long practical acquaintance with the dairy business, that such a consummation can be secured. At the same time great effort will be needed to overcome the foolish prejudice on the part of the labourer against what he considers mere “crankiness.” He must be taught that cleanliness is essential and dirt in any form poison ; but so soon as this belief has been instilled into his mind, and theory and practice work hand in hand, milk will at last take its proper position as pre-eminent among all foods, the first to welcome man’s beginning and the last, often enough, to soothe his end.

H. L. Puxley.

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