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Quality of milk: A far-reaching judgment
1942 of serum disease has fallen to a low figure--in some reports to 4 per cent. or less. The doctor may therefore use modern antitoxin with but little fear of serum reaction. The second difficulty--the early disappearance of antitoxin-conferred immunity--still remains, and presumably will do so until all parents have their children actively immunised. Many immunologists have been attracted by the project of combining the complete temporary protection given by serum with the permanent protection of active immunity. The difficulty revealed long ago by animal experiments is that active immunity does not readily develop in the presence of passive immunity. Hence at the end of about three weeks, when in the average subject the protection given by antitoxin has almost faded, the development of immunity is yet sluggish and does not give reasonable safety. The curve of immunity, actual or potential, is rising and cannot be hurried, but at the end of perhaps four weeks it can be heightened by a second injection of suitable prophylactic. It is in this field that eight workers in conjunction with the Emergency Public Health Service have made a most valuable contribution to our knowledge. Dr. Downie* and four others explored the phenomena following the injection of antitoxin as well as toxoid; Dr. Fultont and four others applied the conclusions of the first group to outbreaks in schools. Downie and his colleagues had about 800 students at their disposal, mostly third-year medical students at Oxford, Cambridge, and Sheffield. For the many carefully analysed immunological points the interested reader will wish to consult the original paper; the broad conclusions are clear. In the course of immunity after active immunisation--e.g., two doses of toxoid separated by a month--there is a gradual progress after the first injection and a sharp rise to a high level of immunity after the second. The giving of antitoxin at the same time as the first prophylactic dose reduces the immunising effect of the first dose. It also retards its sensitising effect, for the curve of immunity after the second dose is more gradual than normal and may reach a slightly lower peak. By the joint method of giving immediate protection with antitoxin and at the same time laying a sound foundation of active immunity with prophlactic, Downie obtained 90 per cent. of conversions from Schick-positive to negative within about eight weeks of the second dose of prophylactic. His students in the " active protection" group---i.e., who received only prophylactic--developed high immuaity: 96 per cent. became negative. We may note that this is below the figure of about 98 per cent. often obtained for groups aged 1 to 14. The group of older students must contain many who have resisted " natural immunisadon" and also respond poorly to active immunlsation. Dr. Fulton, in epidemics of diphtheria in 7 schools with 1,500 pupils on the roll, effectively applied the results got by the first team of workers. Antitoxin, 500 units, was administered to all, and 0.1 c.c. of alum-precipitated toxoid prophylactic (A.P.T.) was given at the same time ; 0.8 c.c. of the A.P.T. was injected four weeks later. All those with positive swabs were isolated and were not re* Brit. ,~led..7., 1941, 2, 717. t Ibid., 1941, 2, 7/59.
PUBLIC HEALTH admitted for six weeks. The results were compicuouslY satisfactory; no attack occurred in anyone who had certainly been through the double course. An unintentional control experiment was provided by some teachers and pupils who for various reasons escaped immunisation. Five eases of diphtheria occurred among them. With regard to the carrier difficulty referred to earlier, if the use of sulphathiazole snuff proves on wider experience to have no disadvantages, and holds out as much promise as the results of Dr. A. M. Thomas ~ indicate, we shall possess another valuable weapon. Thomas gave 10 or 88 per cent. sulphathiazole snuff to nasal carriers of Staph. aureus. Among his patients were twenty nasal carriers of C. diphtheriae. After treatment for a week or two, twelve were immediately and finally cleared of diphtheria bacilli.
Quality of Milk : A Far-reaching Judgment A judgment which may have a serious effect on future prosecutions for selling milk alleged to be diluted was delivered in the King's Bench Division on November 6th by the Lord Chief Justice (Lord Caldecote), Mr. Justice Humphreys, and Mr. Justice Lewis, in the case of Churcher v. Reeves. Samples taken of milk, which was being delivered in Hove, were found to contain only 7.99 per cent. of milk solids other than milk fat instead of the 8.5 per cent. required under the regulations of the Ministry of Agriculture. Evidence was given that according to one test there were just over 2 gallons of added water in a mixture of 86½ gallons, and in another test a little over 4 gallons of added water. The defence was that the farmer had been able to obtain only 66 per cent. of his original pre-war quantity of dairy cake, which is the chief concentrated food for cows, although his herd was larger than before the war, and in consequence of this deprivation the quantity of milk was reduced and its quality deteriorated. The local bench had accepted this view and dismissed the information, coming to the conclusion that the milk was sold to the purchaser in the same condition as it was drawn from the cow. The Hove Council, which had undertaken the prosecution, thereupon appealed, basing its case upon the fact that there was a gap of thirteen hours, from five in the afternoon until six on the following morning, during which the afternoon's milk was left in the dairy not constantly under observation, so that there was ample opportunity for any person to tamper with it. They relied on the case of Jenkins v. Williams, in which, although there was only a gap of two minutes during the delivery of the milk in the street, a previous Divisional Court (of which Mr. Justice Humphreys was also a member) had held that this constituted an interval during which presumably the water could be added. The Lord Chief Justice, in saying that in his view the appeal should be dismissed, quoted the case of Hunt v. Richardson in 1916, in which it was held that the milk was in the condition in which it came from the cow, and that although an analysis had shown a deficiency, this was due to the manner in which the cows had been fed. His Lordship said that the onus Brit. msd. ~t., 1941, 2, 687.
77
PUBLIC HEALTH
JANUARY
of ~ determining matters of fact must be upon the stuffs is universal and causes a deterioration in milk, magistrates, who had accepted the evidence that lack it will apparently be sufficient for any dairyman to of dairy cake had produced deterioration in the milk. urge that as a defence, and the prosecution must fail, T o require it to be shown also that there was no possi- even though it were shown that there was ample opporbility of access by any evil-minded person who would tunity for someone to tamper with the milk. It is well dilute the milk seemed to him to lay down a standard that medical officers of health and public analysts should of proof which went a good deal further than was be aware of the defence set up successfully in this case. necessary. One thing that should immediately be done, if it has "... if the magistrates hear evidence that not been done already, is to establish whether a defithere has been inadequate food and accept the ciency in certain feeding stuffs has a bearing on the evidence to that effect and also evidence to the quantity and quality of the milk, and, if so, exactly effect that lack of dairy food leads to a deficiency what is the relation between lack of feeding stuffs and in milk solids other than fat, I see no reason why, milk deterioration. It appears that the cryoscopic test apart from any evidence at all as to non-access, was not used by the analyst in testing the samples in they should not come to the conclusion that the question. This test is regarded by analysts and has milk was genuine milk." been accepted in courts of summary jurisdiction as Mr. Justice Humphreys, who agreed that the appeal proving whether milk is or is not genuine, whereas should be dismissed, said that the onus was upon the deficiency in solids not fat is not determinative. This respondent to disprove the allegation of the prosecution is an argument which it would have been much more that the milk sold was not genuine milk, which pre- interesting to carry to a higher court. Owing to this sumption arose from the facts and conclusions stated judgment matters are left in an extremely unsatison the analyst's certificate. It was the duty of courts factory position from the point of view of public health. of summary jurisdiction to decide the evidence as to facts. The defendant before the local justices must Typhus first prove that the milk had not been tampered with The Ministry of Health, because of the risk that by himself or his employees, and that there had been typhus may be introduced into large aggregations of no opportunity for anyone else to tamper with it. All population, have asked a number of the principal towns such matters should be present to the minds of the to organise teams for dealing with an outbreak. The justices. That had evidently been so in the present team* is to consist of one medical officer, four nurses, case, and the Court should not interfere with such a an ambulance driver, and an ambulance attendant. It finding when it was shown that the local bench had is suggested that one or more sanitary inspectors and applied their minds to the real question at issue. His trained disinfectors should also be included, and that lordship added a few observations on the case of the team should be duplicated. Members of the team Jenkins v. Williams. He said that if a defendant chose should be provided with protective clothing and be to base his defence upon the evidence of what was offered preventive inoculation. done to the milk or could have been done to it from Typhus is compulsorily notifiable, and the medical the time it came from the cow, his evidence must officer of health must immediately report every case to show that throughout there was no opportunity for the Ministry of Health by telegram or telephone. anyone else to interfere with it. That was the issue Medical officers of health can obtain the services of one in Jenkins v. Williams, and there was no other issue, of the medical staff of the Ministry of Health (or, in and that case could not be cited, in Mr. Justice London, of the L.C.C.) for help in diagnosis. A mobile Humphrey's opinion : - team from the American Red Cross-Harvard Field " as an authority for the proposition that where Hospital Unit will be available for assistance in diagnosis the defence is that there are natural causes which and control in any part of England and Wales. The account for the apparent excess of water in the Ministry urges Medical Officers of Health to consider milk, nevertheless, and after that has been proved, at once the provision of hospital accommodation, and there must in addition be given evidence excluding state that in practice it will probably be advisable to every possibility, however remote, that someone make arrangements with one of the larger isolation other than the defendant or his servants may have hospitals. The patient should be removed to hospital tampered with the milk." in a vehicle easy to free from lice and be enveloped in He added that whether, in the light of the argument a large sheet. The greatest care should be t a k e n t o which he had heard in the present case, he would have protect the staff admitting the patient, who should be arrived at the same conclusion in the case of Jenkins taken to a special bathroom, stripped, de-loused, and v. Williams was a matter of no interest to anyone, clad in hospital garments by protected attendants before perhaps not even to himself. Mr. Justice Lewis was being admitted to the special ward. (The memorandum of the same opinion ; he believed that there was some gives a description and illustrations of the protective evidence upon which the magistrates could find as they clothing.) did. T h e appeal, therefore, was dismissed with costs. Louse-borne typhus fever is an acute infectious Thus in fact the defence of deficiency in feeding disease lasting from twelve to sixteen days. Toxaemia stuffs held good, and the question of tampering with and nervous symptoms are pronounced, t The characthe milk was set aside. But surely there might be other cases in which both factors operated. A farmer might * Memorandum on Louse-Borne Typhus Fever. Ministry have a milk deficient because of lack of feeding stuffs of Health Memo. 252/Med. and also improperly diluted. I f a deficiency in feeding t Brit. reed. y., 1941, 2, 886. 78
PUBLIC HEALTH admitted for six weeks. The results were compicuouslY satisfactory; no attack occurred in anyone who had certainly been through the double course. An unintentional control experiment was provided by some teachers and pupils who for various reasons escaped immunisation. Five eases of diphtheria occurred among them. With regard to the carrier difficulty referred to earlier, if the use of sulphathiazole snuff proves on wider experience to have no disadvantages, and holds out as much promise as the results of Dr. A. M. Thomas ~ indicate, we shall possess another valuable weapon. Thomas gave 10 or 88 per cent. sulphathiazole snuff to nasal carriers of Staph. aureus. Among his patients were twenty nasal carriers of C. diphtheriae. After treatment for a week or two, twelve were immediately and finally cleared of diphtheria bacilli.
Quality of Milk : A Far-reaching Judgment A judgment which may have a serious effect on future prosecutions for selling milk alleged to be diluted was delivered in the King's Bench Division on November 6th by the Lord Chief Justice (Lord Caldecote), Mr. Justice Humphreys, and Mr. Justice Lewis, in the case of Churcher v. Reeves. Samples taken of milk, which was being delivered in Hove, were found to contain only 7.99 per cent. of milk solids other than milk fat instead of the 8.5 per cent. required under the regulations of the Ministry of Agriculture. Evidence was given that according to one test there were just over 2 gallons of added water in a mixture of 86½ gallons, and in another test a little over 4 gallons of added water. The defence was that the farmer had been able to obtain only 66 per cent. of his original pre-war quantity of dairy cake, which is the chief concentrated food for cows, although his herd was larger than before the war, and in consequence of this deprivation the quantity of milk was reduced and its quality deteriorated. The local bench had accepted this view and dismissed the information, coming to the conclusion that the milk was sold to the purchaser in the same condition as it was drawn from the cow. The Hove Council, which had undertaken the prosecution, thereupon appealed, basing its case upon the fact that there was a gap of thirteen hours, from five in the afternoon until six on the following morning, during which the afternoon's milk was left in the dairy not constantly under observation, so that there was ample opportunity for any person to tamper with it. They relied on the case of Jenkins v. Williams, in which, although there was only a gap of two minutes during the delivery of the milk in the street, a previous Divisional Court (of which Mr. Justice Humphreys was also a member) had held that this constituted an interval during which presumably the water could be added. The Lord Chief Justice, in saying that in his view the appeal should be dismissed, quoted the case of Hunt v. Richardson in 1916, in which it was held that the milk was in the condition in which it came from the cow, and that although an analysis had shown a deficiency, this was due to the manner in which the cows had been fed. His Lordship said that the onus Brit. msd. ~t., 1941, 2, 687.
77
PUBLIC HEALTH
JANUARY
of ~ determining matters of fact must be upon the stuffs is universal and causes a deterioration in milk, magistrates, who had accepted the evidence that lack it will apparently be sufficient for any dairyman to of dairy cake had produced deterioration in the milk. urge that as a defence, and the prosecution must fail, T o require it to be shown also that there was no possi- even though it were shown that there was ample opporbility of access by any evil-minded person who would tunity for someone to tamper with the milk. It is well dilute the milk seemed to him to lay down a standard that medical officers of health and public analysts should of proof which went a good deal further than was be aware of the defence set up successfully in this case. necessary. One thing that should immediately be done, if it has "... if the magistrates hear evidence that not been done already, is to establish whether a defithere has been inadequate food and accept the ciency in certain feeding stuffs has a bearing on the evidence to that effect and also evidence to the quantity and quality of the milk, and, if so, exactly effect that lack of dairy food leads to a deficiency what is the relation between lack of feeding stuffs and in milk solids other than fat, I see no reason why, milk deterioration. It appears that the cryoscopic test apart from any evidence at all as to non-access, was not used by the analyst in testing the samples in they should not come to the conclusion that the question. This test is regarded by analysts and has milk was genuine milk." been accepted in courts of summary jurisdiction as Mr. Justice Humphreys, who agreed that the appeal proving whether milk is or is not genuine, whereas should be dismissed, said that the onus was upon the deficiency in solids not fat is not determinative. This respondent to disprove the allegation of the prosecution is an argument which it would have been much more that the milk sold was not genuine milk, which pre- interesting to carry to a higher court. Owing to this sumption arose from the facts and conclusions stated judgment matters are left in an extremely unsatison the analyst's certificate. It was the duty of courts factory position from the point of view of public health. of summary jurisdiction to decide the evidence as to facts. The defendant before the local justices must Typhus first prove that the milk had not been tampered with The Ministry of Health, because of the risk that by himself or his employees, and that there had been typhus may be introduced into large aggregations of no opportunity for anyone else to tamper with it. All population, have asked a number of the principal towns such matters should be present to the minds of the to organise teams for dealing with an outbreak. The justices. That had evidently been so in the present team* is to consist of one medical officer, four nurses, case, and the Court should not interfere with such a an ambulance driver, and an ambulance attendant. It finding when it was shown that the local bench had is suggested that one or more sanitary inspectors and applied their minds to the real question at issue. His trained disinfectors should also be included, and that lordship added a few observations on the case of the team should be duplicated. Members of the team Jenkins v. Williams. He said that if a defendant chose should be provided with protective clothing and be to base his defence upon the evidence of what was offered preventive inoculation. done to the milk or could have been done to it from Typhus is compulsorily notifiable, and the medical the time it came from the cow, his evidence must officer of health must immediately report every case to show that throughout there was no opportunity for the Ministry of Health by telegram or telephone. anyone else to interfere with it. That was the issue Medical officers of health can obtain the services of one in Jenkins v. Williams, and there was no other issue, of the medical staff of the Ministry of Health (or, in and that case could not be cited, in Mr. Justice London, of the L.C.C.) for help in diagnosis. A mobile Humphrey's opinion : - team from the American Red Cross-Harvard Field " as an authority for the proposition that where Hospital Unit will be available for assistance in diagnosis the defence is that there are natural causes which and control in any part of England and Wales. The account for the apparent excess of water in the Ministry urges Medical Officers of Health to consider milk, nevertheless, and after that has been proved, at once the provision of hospital accommodation, and there must in addition be given evidence excluding state that in practice it will probably be advisable to every possibility, however remote, that someone make arrangements with one of the larger isolation other than the defendant or his servants may have hospitals. The patient should be removed to hospital tampered with the milk." in a vehicle easy to free from lice and be enveloped in He added that whether, in the light of the argument a large sheet. The greatest care should be t a k e n t o which he had heard in the present case, he would have protect the staff admitting the patient, who should be arrived at the same conclusion in the case of Jenkins taken to a special bathroom, stripped, de-loused, and v. Williams was a matter of no interest to anyone, clad in hospital garments by protected attendants before perhaps not even to himself. Mr. Justice Lewis was being admitted to the special ward. (The memorandum of the same opinion ; he believed that there was some gives a description and illustrations of the protective evidence upon which the magistrates could find as they clothing.) did. T h e appeal, therefore, was dismissed with costs. Louse-borne typhus fever is an acute infectious Thus in fact the defence of deficiency in feeding disease lasting from twelve to sixteen days. Toxaemia stuffs held good, and the question of tampering with and nervous symptoms are pronounced, t The characthe milk was set aside. But surely there might be other cases in which both factors operated. A farmer might * Memorandum on Louse-Borne Typhus Fever. Ministry have a milk deficient because of lack of feeding stuffs of Health Memo. 252/Med. and also improperly diluted. I f a deficiency in feeding t Brit. reed. y., 1941, 2, 886. 78