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Food poisoning conveyed by raw milk
PUBLIC HEALTH infection in hospitals is one which warrants the best consideration of everyone associated with hospital administration. A committee of the British Medical Association and certain other allied bodies has been dealing with this problem for some time. They have finally concluded that the circumstances in which infections arise are so varied and the infections themselves so various that it is quite impossible to lay down any hard and fast rules as to the steps which should be taken on the occurrence of an infectious case in hospital. They are satisfied that the circumstances of the occurrence of each case must be considered and dealt with in the light of the best scientific knowledge available and with reasonable and proper care. If any endeavour is made to stereotype methods of prevention, progress in this important subject is not likely to be made. The medical officer in charge of the institution must be familiar with the general principles of prevention which he must adapt to the circumstances of any particular case. It is no more possible to standardise methods of prevention than of treatment and to attempt to issue copybook instructions to be followed in this or any other field of medicine would merely result in the sterilisation of thought and initiative and the end of progress.
Hospital Policy Since the transference of Poor Law functions in 1930, it would probably be true to say that hospital and allied services have absorbed the major part of the time and attention of medical officers of health of counties and county boroughs. As Dr. Ferguson pointed out in his contribution to the important discussion reported elsewhere in this issue, this does not mean that the preoccupations of health departments are becoming less preventive and more curative. In the first phase of a revolution immediate needs must have the immediate attention of the chief organiser. There is probably little danger that medical officers of health will forget the preventive background which justifies their presence in the picture. As Dr. Ferguson and so many others have said, it is impossible to separate the curative and preventive functions of any hospital. The transfer, however, of these functions to public health authorities should, in the course of time, remove from the public mind the conception of hospitals as places solely concerned with cure and the alleviation of suffering and bring the recognition that they are not merely to be esteemed for the spectacular snatching of victims from the jaws of death. The new outlook on the treatment of chronic disease, the place of the hospital in the skilled diagnosis and early treatment of disease, the education of hospital 228
MAY patients in a way of living which will prevent the recurrence of their ills, the alleviation of social circumstances inimical to sustained health through the efforts of properly trained hospital almoners, the rehabilitation of accident, including fracture, cases and the raising of the standard of domiciliary diagnosis, treatment and health education by contact of practitioners with hospital practice are all in line with the modern conception of preventive medicine. Of this nature, too, is the prompt treatment in hospital for short periods of disabling troubles, like hernia, hydrocele, varicocele, h~emorrhoids and various gyn~ecological conditions, so restoring to earning or working capacity and mental ease those who are often in danger of becoming valetudinarian. The variety and complexity of the problems of hospital administration are illustrated by the confession of the speakers that they could do no more than mention some of them. Certain broad conclusions seem to emerge. Firstly, it is clear, as we thought from the first, that certain animadversions in Parliament, when the Act of 1929 was in the course of passage, on the capacity of local authorities and their officers to handle hospital problems were quite unjustified. Indeed, for the first time, hospital problems are being faced and solved by trained medical administrators. Secondly, the place of the voluntary and municipal hospitals must be more clearly defined, and the lines of development of each demarcated. To leave this problem to solve itself by unguided local views and prejudices would be wasteful. Thirdly, there must be closer co-operation between local authorities and the managers of voluntary hospitals, if and so long as they continue to work side by side. Lastly, it is inconceivable that a coherent hospital policy can be worked out, at least, in many areas, without some system of enlargement of districts for hospital service both of a voluntary and statutory kind. Medical officers of health can do much to counteract the excessive parochialism of some authorities which hinders the adoption of co-operative schemes.
Food Poisoning Conveyed by Raw Milk The Ministry of Health have published a report* on the outbreak of food poisoning at Wilton in Wiltshire, which yields yet one more illustration of the dangers of our raw milk supply. The following are the essential facts. The outbreak was limited to the consumers, chiefly children supplied with school milk, of a * A Report on an Outbreak of Food Poisoning due to Salmonella, type " Dublin," and Conveyed by Raw Milk. By E. T. Conybeare and L. H. T. Thornton. No. 82. H,M. Stationery Office. Price 2d.
1938
PUBLIC H E A L T H
particular supply of raw milk on October 28th and health experts on this subject desire, it yet will be 29th, 1936. Over 100 persons were attacked with a material step forward in the right direction. One other point deserves mention in connection gastro-enteritis symptoms, which in some were severe, but fortunately with no deaths. The with this outbreak. Most of the sufferers were incubation period was 12 to 24 hours and this and school children supplied with milk through the the other facts suggested infection with a lung Education Authority, and parents ought to be able bacillus. Salmonella Dublin was isolated from the to assume that any milk so supplied could be milk on two occasions subsequent to the outbreak. accepted as safe from the risk of conveying disease. Its causal relationship was confirmed by the The responsibility for approving the supply is presence in the blood of nine convalescents of upon the medical officer of health and the school specific agglutinins of type " D u b l i n " in litres medical officer. With our knowledge of the way varying from 1 : 600 to 1 : 2500. A detailed disease is spread by raw milk, it is to be regretted investigation for specific agglutinins in the herd of that it has not so far been possible for every 51 cows gave positive diagnostic reactions, all medical officer to insist that all milk supplied to probably associated with " D u b l i n " infections. school children shall be pasteurised, or at least This Salmonella type is known to be a cause of from tuberculin-tested herds. bovine infections (calf dysentery) and may be regarded as a bovine strain. The dung of one of The Poliomyelitis Epidemic in Victoria these three cows was found to be very heavily The first circumstantial account of the recent contaminated with this bacillus, although it was epidemic of acute anterior poliomyelitis in Melnot being excreted in the milk. In view of the last bourne and the rest of Victoria is contained in the fact and that the mechanical milking plant was latest issue of the Health Bulletin of the State defective and the technique defective, thus allowing Department of Health.* The highest incidence dung to gain access to the milk, suggests that it was in any previous year was 303 cases in 1918 but the in this way that infection was conveyed. disease had assumed epidemic proportions in 1931 There is already on record a considerable number and 1934. Until last year its seasonal behaviour of food poisoning outbreaks spread by milk and had been normal, the greatest number of cases many have been associated with a cow-infected occurring in the warm months of each year, i.e., milk and Salmonella strain. from November to May in the Southern HemiThe list of infections spread by milk is a formid- sphere. In the 1937 epidemic, however, the first able one and additions are regularly being made case was reported on June 21st (mid-wiriter). The and will continue to be made so long as raw milk tally of reported cases in succeeding months in the is allowed to be utilised. As Sir Arthur MacNalty Metropolitan area alone was, July 37, August 170, states in his introduction, " No amount of care in September 172, October 219, November 252, milking and distribution of such raw milk can December 193 and January (1938) 171. The prevent it from being a danger to the consumer. corresponding figures for the rest of the State were In other words, a clean raw milk is not necessarily 0, 14, 15, 50, 97, 192, 188. The peak, therefore, a safe milk." The medical profession, and par- was reached in Melbourne in November when the ticularly the public health service, needs to con- first cases would usualIy be expected, and it was tinue to reiterate that cleanliness alone cannot delayed only by about a month in the rest of the ensure safety, and that none of the steps which are State. Up to the end of January 1,214 cases had so widely acclaimed to produce a cleaner milk by been notified in Melbourne and 556 in areas special designations such as " accredited " materi- beyond that city. In comparing this with recent ally increases the safety factor. As Sir Arthur epidemics in other countries, e.g., Denmark,t it points out, " The only practical way to reduce the should be noted that the great majority of these risk of such outbreaks to a minimum is by efficient eases were paralytic, requiring prolonged hospital pasteurisation or by some other suitable form of and domiciliary care. For instance, of about 1,200 heat treatment, and this applies with still greater cases treated at the Melbourne Hospital for force in the case of bulked milk supplies where the Infectious Diseases, Fairfield, not more than 60 risk is commensurately increased." We know failed to show paralysis. Severity as measured by that pasteurisation properly carried out is efficient the fatality rate depends on the completeness of to secure safety, does not affect the nutritive value ascertainment. In this epidemic 68 of the first of milk, and can be very accurately controlled. 1,159 patients admitted to hospital up to January Opposition to it is based on prejudice and the fear 28th had died, a fatality rate of nearly 6 per cent. of interference with trade. It is to be hoped that * State of Victoria, Department of Public Health ; Health the enunciated Government " Milk Policy " will Nos. 51 and 52 (July-December), 1937. 295, Queen soon be embodied in an Act of Parliament, and, Bulletin, Street, Melbourne. although it does not go nearly as far as most public t Jensen, Claus. Proc. Roy. Soc. Med. (1935). 28, 1007 229
Hospital Policy Since the transference of Poor Law functions in 1930, it would probably be true to say that hospital and allied services have absorbed the major part of the time and attention of medical officers of health of counties and county boroughs. As Dr. Ferguson pointed out in his contribution to the important discussion reported elsewhere in this issue, this does not mean that the preoccupations of health departments are becoming less preventive and more curative. In the first phase of a revolution immediate needs must have the immediate attention of the chief organiser. There is probably little danger that medical officers of health will forget the preventive background which justifies their presence in the picture. As Dr. Ferguson and so many others have said, it is impossible to separate the curative and preventive functions of any hospital. The transfer, however, of these functions to public health authorities should, in the course of time, remove from the public mind the conception of hospitals as places solely concerned with cure and the alleviation of suffering and bring the recognition that they are not merely to be esteemed for the spectacular snatching of victims from the jaws of death. The new outlook on the treatment of chronic disease, the place of the hospital in the skilled diagnosis and early treatment of disease, the education of hospital 228
MAY patients in a way of living which will prevent the recurrence of their ills, the alleviation of social circumstances inimical to sustained health through the efforts of properly trained hospital almoners, the rehabilitation of accident, including fracture, cases and the raising of the standard of domiciliary diagnosis, treatment and health education by contact of practitioners with hospital practice are all in line with the modern conception of preventive medicine. Of this nature, too, is the prompt treatment in hospital for short periods of disabling troubles, like hernia, hydrocele, varicocele, h~emorrhoids and various gyn~ecological conditions, so restoring to earning or working capacity and mental ease those who are often in danger of becoming valetudinarian. The variety and complexity of the problems of hospital administration are illustrated by the confession of the speakers that they could do no more than mention some of them. Certain broad conclusions seem to emerge. Firstly, it is clear, as we thought from the first, that certain animadversions in Parliament, when the Act of 1929 was in the course of passage, on the capacity of local authorities and their officers to handle hospital problems were quite unjustified. Indeed, for the first time, hospital problems are being faced and solved by trained medical administrators. Secondly, the place of the voluntary and municipal hospitals must be more clearly defined, and the lines of development of each demarcated. To leave this problem to solve itself by unguided local views and prejudices would be wasteful. Thirdly, there must be closer co-operation between local authorities and the managers of voluntary hospitals, if and so long as they continue to work side by side. Lastly, it is inconceivable that a coherent hospital policy can be worked out, at least, in many areas, without some system of enlargement of districts for hospital service both of a voluntary and statutory kind. Medical officers of health can do much to counteract the excessive parochialism of some authorities which hinders the adoption of co-operative schemes.
Food Poisoning Conveyed by Raw Milk The Ministry of Health have published a report* on the outbreak of food poisoning at Wilton in Wiltshire, which yields yet one more illustration of the dangers of our raw milk supply. The following are the essential facts. The outbreak was limited to the consumers, chiefly children supplied with school milk, of a * A Report on an Outbreak of Food Poisoning due to Salmonella, type " Dublin," and Conveyed by Raw Milk. By E. T. Conybeare and L. H. T. Thornton. No. 82. H,M. Stationery Office. Price 2d.
1938
PUBLIC H E A L T H
particular supply of raw milk on October 28th and health experts on this subject desire, it yet will be 29th, 1936. Over 100 persons were attacked with a material step forward in the right direction. One other point deserves mention in connection gastro-enteritis symptoms, which in some were severe, but fortunately with no deaths. The with this outbreak. Most of the sufferers were incubation period was 12 to 24 hours and this and school children supplied with milk through the the other facts suggested infection with a lung Education Authority, and parents ought to be able bacillus. Salmonella Dublin was isolated from the to assume that any milk so supplied could be milk on two occasions subsequent to the outbreak. accepted as safe from the risk of conveying disease. Its causal relationship was confirmed by the The responsibility for approving the supply is presence in the blood of nine convalescents of upon the medical officer of health and the school specific agglutinins of type " D u b l i n " in litres medical officer. With our knowledge of the way varying from 1 : 600 to 1 : 2500. A detailed disease is spread by raw milk, it is to be regretted investigation for specific agglutinins in the herd of that it has not so far been possible for every 51 cows gave positive diagnostic reactions, all medical officer to insist that all milk supplied to probably associated with " D u b l i n " infections. school children shall be pasteurised, or at least This Salmonella type is known to be a cause of from tuberculin-tested herds. bovine infections (calf dysentery) and may be regarded as a bovine strain. The dung of one of The Poliomyelitis Epidemic in Victoria these three cows was found to be very heavily The first circumstantial account of the recent contaminated with this bacillus, although it was epidemic of acute anterior poliomyelitis in Melnot being excreted in the milk. In view of the last bourne and the rest of Victoria is contained in the fact and that the mechanical milking plant was latest issue of the Health Bulletin of the State defective and the technique defective, thus allowing Department of Health.* The highest incidence dung to gain access to the milk, suggests that it was in any previous year was 303 cases in 1918 but the in this way that infection was conveyed. disease had assumed epidemic proportions in 1931 There is already on record a considerable number and 1934. Until last year its seasonal behaviour of food poisoning outbreaks spread by milk and had been normal, the greatest number of cases many have been associated with a cow-infected occurring in the warm months of each year, i.e., milk and Salmonella strain. from November to May in the Southern HemiThe list of infections spread by milk is a formid- sphere. In the 1937 epidemic, however, the first able one and additions are regularly being made case was reported on June 21st (mid-wiriter). The and will continue to be made so long as raw milk tally of reported cases in succeeding months in the is allowed to be utilised. As Sir Arthur MacNalty Metropolitan area alone was, July 37, August 170, states in his introduction, " No amount of care in September 172, October 219, November 252, milking and distribution of such raw milk can December 193 and January (1938) 171. The prevent it from being a danger to the consumer. corresponding figures for the rest of the State were In other words, a clean raw milk is not necessarily 0, 14, 15, 50, 97, 192, 188. The peak, therefore, a safe milk." The medical profession, and par- was reached in Melbourne in November when the ticularly the public health service, needs to con- first cases would usualIy be expected, and it was tinue to reiterate that cleanliness alone cannot delayed only by about a month in the rest of the ensure safety, and that none of the steps which are State. Up to the end of January 1,214 cases had so widely acclaimed to produce a cleaner milk by been notified in Melbourne and 556 in areas special designations such as " accredited " materi- beyond that city. In comparing this with recent ally increases the safety factor. As Sir Arthur epidemics in other countries, e.g., Denmark,t it points out, " The only practical way to reduce the should be noted that the great majority of these risk of such outbreaks to a minimum is by efficient eases were paralytic, requiring prolonged hospital pasteurisation or by some other suitable form of and domiciliary care. For instance, of about 1,200 heat treatment, and this applies with still greater cases treated at the Melbourne Hospital for force in the case of bulked milk supplies where the Infectious Diseases, Fairfield, not more than 60 risk is commensurately increased." We know failed to show paralysis. Severity as measured by that pasteurisation properly carried out is efficient the fatality rate depends on the completeness of to secure safety, does not affect the nutritive value ascertainment. In this epidemic 68 of the first of milk, and can be very accurately controlled. 1,159 patients admitted to hospital up to January Opposition to it is based on prejudice and the fear 28th had died, a fatality rate of nearly 6 per cent. of interference with trade. It is to be hoped that * State of Victoria, Department of Public Health ; Health the enunciated Government " Milk Policy " will Nos. 51 and 52 (July-December), 1937. 295, Queen soon be embodied in an Act of Parliament, and, Bulletin, Street, Melbourne. although it does not go nearly as far as most public t Jensen, Claus. Proc. Roy. Soc. Med. (1935). 28, 1007 229