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give opportunities to the Council’s medical staff ofinstruction in the most modern methods of treat-

ment ; patients from any of the Council’s hospitalscan be sent to Hammersmith for the purpose of

diagnosis and the specialised treatment availablethere. The hospital is situated in a rapidly growingneighbourhood-East Acton has sprung up almostin a night-and there is no casualty departmentnearer than the West London Hospital, 11 miles

away. The department occupies the whole south

wing of the east block, and is situated just oppositethe main entrance to the hospital. Nearest to the

gate is the entrance for casualties adjoining the

porter’s lodge ; here are two small wards separatedby the nurses’ room, with ready access to all theother facilities of the department. The entrance for

out-patients is in the centre of the block, and opensinto a top-lighted waiting hall with sitting room for300 persons, served by a canteen. Opening out ofthis hall are two rooms for the lady almoners andsuites of consulting and examination rooms, includinga theatre for minor operations with recovery room.There is a separate antenatal section with its ownentrance. A large new dispensary serves both themain hospital and the out-patients, who have theirown entrance and exit. The first floor of this block,which is much reduced in size, contains on the oneside a large X ray therapy section, and on the otherdental rooms, rooms for heart and lung and gastro-intestinal cases, conveniently separated by the darkroom, a fracture room, and various other roomswhose use is likely to be determined by experience.The second floor of this block will remain in skeletonpending ultimate requirements.We may conclude this account of the buildings

themselves with a reminder that the agreementbetween the London County Council and the Govern-ing Body of the School may be considered to be of apermanent character, although the licence granted tothe School for occupation of the new premises isrestricted to a term of 999 years. The appointmentof the professorial and technical staffs is a matterfor agreement between the two bodies. The responsi-bility for the care of patients will continue to restwith the Council, and while the proper duty of theSchool is teaching the two functions are in practiceinseparable, at least with regard to the more seniorposts. The School will depend for its main incomeon a grant from the University Grants Committeeadministered through London University (which hastwo representatives on the Governing Body), but willalso receive a payment from the Council in respect ofservices rendered to the hospital, and, in addition,fees will be charged to students attending courses.The agreement between the two bodies further pro-vides for the setting up of a joint committee, on whichthe School and the hospitals and medical servicescommittee of the Council will be equally represented,in order to determine all matters of joint concern.

COVENTRY AND WARWICKSHIRE HOSPITAL.-Themanagement of this hospital has decided to acquirethe adjoining City Fever Hospital, alter, enlarge, andequip it as an extension. An appeal is therefore beingissued for 100,000, which would make it possible to payoff the overdraft of 25,000. The existing facilities havebecome hopelessly inadequate. The out-patients’ depart-ment can no longer cope with its rapidly growing attend-ances, and there is a waiting-list of between 150 and 200,and delicate technical treatments are being given in crowdedand unsuitable temporary premises. The extension fundat present stands at about 30,000, and the cost of acquiringthe City Hospital will be E65,000.

SURPLUS MILK AND SAFE MILK

A POLICY IN OUTLINE

THE steps the Government proposes to take toincrease the consumption of milk and improve thesupply were described in the House of Commons 1on Feb. 22nd. Anxiety, however, has been expressedin the medical journals 2 and elsewhere lest the

advantage of greater consumption should be boughtat the price of safety-especially the safety of children-and it has been emphasised that the support ofthe profession will be withheld from schemes whichdo not include satisfactory arrangements for pre-venting the transmission of bovine infections.On March 8th a meeting was held at the London

School of Hygiene and Tropical Medicine, with Prof.G. S. Wilson in the chair, and a memorandum on theGovernment’s milk policy was drawn up. Wepublish here a list of the signatories, followed bypassages representing the greater part of theirstatement.

Dr. J. A. ABEWBiGHT, F.R.S., hon. member of bacterio-logical staff at the Lister Institute of Preventive Medicine ;member of the Medical and Agricultural Research Councils.

Mr. J. C. DRUMMOND, D.Sc., professor of biochemistryin the University of London, at University College.

Prof. J. C. G. LEDINGHAM, M.D., F.R.S., director andchief bacteriologist of the Lister Institute.

Mr. F. C. MINETT, D.Sc., director of the research instituteat the Royal Veterinary College.

Prof. H. RAISTRICK, F.R.S., professor of biochemistryin the University of London, at the London School ofHygiene and Tropical Medicine.

Dr. G. S. WMSON, professor of bacteriology as appliedto hygiene in the University of London, at the LondonSchool of Hygiene.Mr. N. C. WRIGHT, Ph.D., director of the Hannah Dairy

Research Institute.

The MemorandumThe desirability of increasing the consumption of

liquid milk is admitted on both economic and publichealth grounds. Investigations on children haveshown conclusively the value of a daily ration of milkin promoting physical growth and development.There is reason to believe that the raising of theper caput consumption of milk from its present valueof between one-third and two-fifths of a pint to ahigher level would be attended by most beneficialresults. A propaganda campaign to achieve this

object would probably receive the strong supportof the medical and veterinary professions, providedsatisfactory assurances were given as to the safetyof the milk so supplied.

NECESSITY FOR A SAFE MILK-SUPPLY

Evidence is accumulating rapidly that the raw milk-supply of this country is often heavily infected withmicro-organisms capable of producing disease in man.An average of 6-7 per cent., running up in somedistricts to as much as 20 per cent., of samples of rawmarket milk are infected with virulent bovinetubercle bacilli. Approximately 20-30 per cent. ofraw milk samples can be demonstrated to containBrucella abortus which causes both contagious abortionin cattle and undulant fever in man. It is thereforenot surprising that in England and Wales about 2000deaths every year, mainly in children, occur fromtuberculosis of bovine origin, and that at least 4000fresh cases of this disease are notified annually. Theoccurrence of undulant fever has only been recognisedof late years in this country, and its exact incidence

1 THE LANCET, March 3rd, p. 491.2 THE LANCET, Feb. 24th, p. 405, and March 10th, p. 526 ;

Brit. Med. Jour., Feb. 24th, p. 339.

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is unknown. There are grounds, however, for believ-ing that about 500 cases of active infection withBrucella abortus, derived to a considerable extent frommilk, occur annually in England and Wales. Thisestimate, it may be noted, agrees well with the figuresof other countries having a similarly infected bovinepopulation.

Besides tuberculosis and undulant fever, numerousmilk-borne outbreaks of scarlet fever, septic sore-

throat, diphtheria, enteric fever, dysentery, andgastro-enteritis have occurred of late years. We maymention, in particular, two recent outbreaks, one ofseptic sore-throat at Hove resulting in over 1200

primary cases with 65 deaths, due incidentally toconsumption of raw milk coming from an exceptionallywell-managed farm, and one of paratyphoid fever atEpping involving 312 persons with 8 deaths.

It is impossible scientifically to escape the implica-tion of these facts-namely, that no raw milk can beguaranteed as safe for human consumption. Milkfrom tuberculin-tested herds is for all practical pur-poses free from the risk of conveying tuberculosis,but, as experience both in this country and theUnited States has shown, it is capable of carryingother infections.

Milk is so liable to contamination, not only fromthe cow, but also from infected water-supplies usedfor cleaning utensils, and from human carriers andearly -cases of disease during its production and

distribution, that it must always be considered as

potentially dangerous in the raw state.We do not wish to convey an exaggerated impres-

sion of the frequency of milk-borne disease, but wedo wish to point out that the potential dangers ofraw milk are such as to preclude members of themedical profession who are acquainted with the facts,and who are responsible for the health of those undertheir care, from recommending it for human con-sumption.The logical conclusion to which this argument

leads is that all liquid milk should be submitted tosome form of adequate heat treatment, preferablylow-temperature pasteurisation. There is no doubtthat pasteurisation carried out under commercialconditions in properly designed plant efficientlyoperated can be relied upon to render milk safe.We are of opinion that ordinary raw milk should bepasteurised under official control, and that every stepshould be taken to ensure that pasteurisation is

efficiently performed.There is reason to believe that if the present Milk

Designations Order was amended so as to permitof the pasteurisation of milk from tuberculin-testedherds it would meet with strong support from themedical profession. Hitherto very little progresshas been made in the establishment of these herds,partly because the medical profession has no confidencein the safety of Certified and Grade A (T.T.) milk,so far as the risk of conveying diseases other thantuberculosis is concerned. If permissive powerswere given to pasteurise milk from tuberculin-testedherds, there would become available a clean safe milk,which we venture to believe would receive verystrong support from the medical profession. Experi-ence in the United States may be called upon tojustify the truth of this prediction.The evidence at present available affords no support

to the statement still frequently made that pasteurisa-tion seriously diminishes the nutritive value of themilk. The expression of opinion in the Report ofthe Medical Research Council for the year 1932-1933amply bears out this conclusion.

There are strong grounds for believing that theadequate pasteurisation of all liquid milk intendedfor human consumption in this country would abolishthe yearly toll of disease and death due to milk-borneinfection, and we can see no reason why steps shouldnot be taken to hasten the achievement of this highlydesirable result.OUTLINE OF A MILK POLICY BASED ON SCIENTIFIC

PRINCIPLES

The purpose of this memorandum is to offer con.structive criticism, and we therefore submit the

following proposals outlining a policy which mightobtain the support of medical, veterinary, andagricultural interests.

(1) Stimulation of clean milk production.-Experi-ence has shown that the production of milk free fromdirt and excessive numbers of micro-organisms is

possible if a few essentials are adhered to, such aswashing of the milker’s hands, washing of the cow’sudder, and, most important of all, sterilisation of

milking utensils. The carrying out of these measuresis largely provided for in the Milk and Dairies Order,1926, and enforcement of this Order would necessarilyresult in a considerable improvement in the cleanlinessof the milk-supply. We would emphasise that dirtymilk cannot be made clean by pasteurisation, andthat only with milk produced under cleanly conditionsis it possible to obtain a satisfactory pasteurisedproduct. ’

(2) Permissive -powers of compulsory pasteurisationshould be given to towns of 10,000 inhabitants andover. The adequate supervision of pasteurisingplants by the local authority should be made obli-gatory, so as to justify the confidence that the publicplaces in pasteurised milk. Consideration should be

given to the possible use of small pasteurising plantsby producers in rural districts. All raw milk thatcannot be adequately pasteurised should be boiledfor use.

(3) Establishment of a pre-pasteurisation standard ofcleanliness.-It is often urged that pasteurisationdiminishes the incentive to produce clean milk. This,we maintain, is unjustifiable. A clean milk is almostas desirable as a safe milk, and the aim for whichwe must all work is a milk produced under cleanlyconditions from healthy animals rendered safe bypasteurisation and distributed in sterilised bottles.A pre-pasteurisation standard of cleanliness, to whichall milks intended for pasteurisation must conform,would stimulate enormously the production of cleanmilk. Such a standard, we believe, is quite possibleto set up, and provided it is interpreted liberally inthe early stages of its operation, no undue hardshipshould result.

(4) Alteration and simpl1fication of the presentgrading system, with permissive powers of pasteurisationof milk from tuberculin-tested herds.-We do not

propose to suggest new designations at the moment,since they will need a considerable amount of dis.cussion. We do’ wish, however, to suggest thatpermissive powers of pasteurisation of milk fromtuberculin-tested herds will stimulate enormouslythe establishment of this type of herd, and will aidthe veterinary profession in its campaign againstbovine tuberculosis. Pasteurised tuberculin-testedmilk will be the cleanest and safest milk on themarket ; its retail price should not be more than 2d.a quart dearer than ordinary pasteurised milk; andit is likely to receive strong recommendation from themedical profession

(5) While in thorough agreement with the desireof the Government to clean up the milking herds of

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the country, we feel that nothing short of the establish-ment . of tuberculin-tested herds on lines similar in

principle to- those that have proved so successfulin the United States of America is worth seriouscontemplation. Though clinical inspection and

bacteriological sampling of the milk may eliminatea certain number of animals with obvious disease,they can have little ultimate effect on the extent ofinfection, since animals with clinically detectabledisease constitute only a fraction of the total numberinfected with the tubercle bacillus. They do notaccomplish the eradication of tuberculosis, nor dothey provide a sufficient guarantee of safety for themilk-supply to justify its increased consumption.We therefore favour a plan, based at first on voluntarycooperation, for the gradual establishment of tuber-culin-tested herds, and for the paying of a premiumon the milk from such herds whether intended forpasteurisation or not.

(6) We urge that the 750,000 promised for improv-ing the purity of the milk-supply, and of the 500,000for propaganda purposes, should be devoted to

.furthering the suggestions laid down in this memo-randum rather than on the proposals at presentcontemplated by the Government.

(7) We further urge that before any definitelegislation is introduced, a committee should ’beappointed consisting of representatives of the pro-ducing and distributing interests, and of the Ministriesof Health and Agriculture, together with independent.scientific authorities, to draw up a plan for the imme-diate improvement in the cleanliness and safety ofthe milk-supply of Great Britain. We believe thatvery striking results might be achieved in a shorttime at comparatively slight cost if only agreementon fundamental principles was reached. The pro-vision of a clean safe milk-supply is possible only ifmedical, veterinary, and agricultural interests are

united in the support of a plan based on scientificknowledge. The time seems to us to be ripe for thetranslation. of scientific knowledge into current

practice.A Deputation to the Ministers

On March 27th Sir Hilton Young (Minister of

Health) and Mr. Walter Elliot, M.B. (Minister of

Agriculture), received a deputation introduced bySir Austen Chamberlain as chairman of the governingbody of the London School of Hygiene. The memberswere Prof. Wilson, Dr. Arkwright, Prof. Ledingham,Dr. Minett, Prof. Raistrick, and Dr. Wright, andtheir object was to urge the valency of the views setout in their memorandum. In reply the Ministersstated that the points raised were under examinationby the Cattle Diseases Committee of the EconomicAdvisory Council, and the report of the committeeand the views of the deputation would receive thecareful consideration of the Government. The

legislation about to be introduced would be in generalterms, and would permit full consideration to be givenat a later stage to the matters under discussion.

HOSPITAL COSTS.-Last year the average total cost ofeach of 2309 in-patients at Worcester Infirmary was ;E7 10s.,as compared with 6 10s. in .1932. The average cost peroccupied bed was E136 9s. 9d., as against f.l29 18s. 10d. inthe previous year. Each out-patient cost 10s. 5d., a frac-tional fall.-At the Chelmsford and Essex Hospital lastyear in-patients (1877) cost Y3 5s. 7d. each per week, anincrease of 9s. 6d. per patient ; the explanation of the risewas that there were 132 fewer in-patients.-At CroydonGeneral Hospital 2576 in-patients (daily average 116 ;average stay 16-5 days) cost E6 16s. 7d. on the average.

HOOKWORM ANÆMIA : ACUTE AND

CHRONIC

ACUTE ankylostomiasis is an entity which has beentoo little studied, and it is useful to have the observa-tions now reported by B. K. Ashford and G. C. andF. K. Payne.’ The outbreak they describe was in PortoRico and concerned seven previously healthy persons,of whom six bathed in the sea at a spot where a muddyinfective stream was discharging flood water. Thewhole of those parts of their bodies under their bathingsuits became covered with intensely irritating " bites,"and acute illness set in with fever, rawness of thethroat making swallowing difficult, epigastric painand vomiting, diarrhoea, intestinal haemorrhage,and rapidly developing asthenia and pallor. Inthe most serious case typhoid with haemorrhagebut with delayed agglutination had been diagnosed,but Colonel Ashford was satisfied that he was facedby acute ankylostomiasis, a diagnosis justified by thefirst appearance of the eggs in the faeces a few dayslater. Noteworthy is the presence of fever which,it appears, has also been demonstrated as a featureto be expected in acute Mansonian schistosomiasisin Porto Rico. In every case blood, patent or occult,was found in the faeces, and in the most serious ofthem the loss was so great that the patient’s life wasonly saved by two blood transfusions. The throat

symptoms were evidently due to the presence oflarvse there during their well-known passage fromskin to intestine. On the digestive symptoms lighthas been thrown by J. Stewart, whose experience isthat heavy nematode infections lessen proteindigestion, while from the worms themselves can beextracted a body (he terms it nezyme) which in-vitroexperiments show to inhibit the action of pepsin ;the effects on intestinal digestion will doubtless beinvestigated later.

These cases, as well as that of a seventh child whohad not bathed but had delved with her hands inthe mud bordering the infected stream, were followedby Ashford through daily, and later less frequent,blood examinations for a year ; and by the Paynesthrough examinations of all stools for a month andafterwards on all occasions of anthelmintic treatment,these examinations being so minute as to recover

young worms only 1-8 mm. long. Although all butthe child bathed for about the same period andappeared to have been about equally peppered with" bites," it is significant that the number of wormsrecovered varied from 21 to 1439, and from the delvingchild 7 only. The blood changes were remarkable :a leucocytosis, preponderatingly eosinophilic, reachingits maximum three to four months after infection,the eosinophils in the last case comprising 90 per cent.of all leucocytes. The explanation offered for thisstriking condition is that it was due to strayed larvaesurviving in numbers in the tissues for that periodand then mostly dying, an explanation which thoughmerely inferential at present will have to be in themental foreground in future work. At all eventsthe fact that such close and skilled faecal examinationsdisclosed only 7 worms in one whose h2emoglobinfell to 60 per cent. and erythrocytes to 3,824,000should give pause to those who hold that 25 intestinalhookworms constitute a negligible load.As to the cause of the anaemia, the presence and

influence of blood loss were unquestionable in theseacute cases. But that it wholly explains that ofchronic hookworm infection is questioned by C. D.