- Email: [email protected]
SIC TRANSIT
1250
Annotations
Buyers
are
recommended
to
carry out
periodic
checks
incoming milk; and the other Milk Marketing Boards should consider introducing a system of price penalties for milk found to contain antibiotics, on the lines proposed on
ANTIBIOTICS IN MILK
ANTIBIOTICS are much used in the treatment of mastitis in cows, and traces of them are present in the animal’s milk for some days after treatment. In January, 1960, the Milk Hygiene Subcommittee of the Milk and Milk Products Technical Advisory Committee decided to undertake a survey to determine how much penicillin and other antibiotics were getting into milk in Britain. The findings are given in a reportI published last week. The survey started in January, 1961, in England and Wales, and in February, 1961, in Scotland and continued in each case for twelve months. Milk was sampled and tested at 51 centres in England and Wales and 5 in Scotland, the centres being selected to provide a representative sample of milk from each area. Penicillin was the antibiotic most commonly found. In England and Wales over 41,700 samples were examined during the year, and 11%, representing 14% of the total milk sampled, contained antibiotics. The lowest incidence (7-7%) was found in October and the highest (16.6%), in January. In Scotland, out of over 2700 samples, 99% (11-6% of the milk sampled) contained antibiotics. The lowest incidence (4-7%) was found in July, and the highest (13-8%) in May. The view of the medical advisers on the Antibiotics in Milk Panel of the Ministry of Health is that the presence in milk of any antibiotic is undesirable because of the possible ill effects on the health of a few individuals in the population. Firstly, there is the danger that the consumption of small quantities of antibiotics may sensitise some people, rendering them liable to severe reaction if therapeutic doses of these drugs are required later. Secondly, there is the danger of allergic reaction, particularly skin rashes, in a few people who are already highly reactive to penicillin. Thirdly, as a result of treatment with penicillin, strains of penicillin-resistant staphylococci that cause bovine mastitis are alleged to be increasingly common and there is a danger that any illness such organisms may cause in man will not respond to treatment with penicillin. The report recommends that manufacturers of antibiotics should be asked to provide formulations suitable for the treatment of most cases of mastitis and having an excretion-time of less than 48 hours; and that manufacturers should label their preparations to show the minimum length of time that milk from treated animals should be withheld. Veterinary surgeons could help to reduce the amount of antibiotics likely to be present in milk by restricting the quantity they leave with farmers. They could also impress upon farmers the importance of keeping back milk from treated animals for the period stated on the label. Notification to the buyer that antibiotic treatment had been given would also be helpful, since it would enable a check to be kept on milk from that farm. The British Veterinary Association has been asked informally whether its members would cooperate in this way and has indicated that it could not agree with the suggestion regarding notification which would, in its view, be a breach of professional etiquette. The Association has agreed, however, to do everything possible to see that farmers are reminded of their obligations with regard to disposal of milk from treated animals. 1. Antibiotics in Milk in Great Britain. Is. 3d.
H.M.
Stationery
Office.
Pp.
10.
the Scottish Milk Marketing Board. Food and drugs authorities should be encouraged to sample and test ex-farm milk for the presence of antibiotics and to take appropriate action. The subcommittee would also like to see a publicity campaign to ensure that producers are constantly reminded of the necessity to observe all precautions in order that the milk supply shall be free from traces of antibiotics.
by
SIC TRANSIT
WE have probably witnessed the last major experiment in simple orbital flight, which may be expected to become part of the training syllabus for astronauts and technicians rather than the goal. The next phase, already begun by Russia, is to prove the means of rendezvous in flight and the transfer of men and stores from one orbiting vehicle to another-matters which are mainly technological. Beyond is the prospect of the habitable artificial satellite, from which to launch true Space travel; and there are many uncertainties upon the health, welfare, and safety of the men who will one day set out to explore the infinite. Some of these uncertainties have to do with what are, broadly speaking, physiological factors: the consequences to the circulatory, muscular, and nervous systems of prolonged weightlessness and inactivity; how to maintain body metabolism for months when storage space is severely restricted; by what means to provide for respiratory exchange and to control the environment of temperature, pressure, and humidity; and how to limit exposure to ionising radiations. Some of the uncertain factors are both physiological and psychological: the effects of disorientation during manoeuvre; the clouding of consciousness when normal stimuli are suspended; fear of the unknown, as time slowly passes in isolation. All these we now recognise to be the preoccupations of Space medicine; but when long voyages are undertaken, older and less esoteric complications will be encountered. As the astronaut loses his exclusiveness, becoming one of a small crew, there will be the personality clashes inevitable among men under constant stress at very close quarters. There will also be the risk of illness, which could, as in the long voyages of exploration in the days of sail, bring disaster on a well-found enterprise. An attack of infectious hepatitis, for example, between Earth and Mars, is unpleasant to contemplate, and the disease is not so rare that the possibility can be ignored. It is, indeed, the infectious diseases of viral origin which seem the most difficult to provide against, partly because they are not easy to treat and partly because the incubation period is generally long. A month’s complete isolation before the launching would be a tedious start.
Sudden incapacitating illness-for example, coronary thrombosis-as a cause of aircraft accidents is always in the mind of those who investigate unexplained crashes. As a rule, it has to be set down as one of several possibilities, because there is no evidence either way; for disasters to aircraft with a single pilot are nearly always catastrophic. Though in a young, fit population the risk must be small compared with the occupational physiological hazards such as anoxia, it is real enough to direct the interest of those responsible for the care of aviators
1251
towards means of detecting latent coronary heart-disease 1; and this is an obvious approach for the screening of astronauts, who are subjected to every possible physiological investigation before selection and before each flight. Infectious disease is hardly a hazard to aviators whose flights, compared with incubation periods, are exceedingly brief; but on two counts it must now enter the reckoning of Space medicine: first because it can affect the astronaut in transit; and secondly because it is " It an undesirable export. In the words of Generales: would be well to recall that the medical profession has still not eradicated syphilis since its introduction into Europe about 1493 and the explosive epidemic of Naples in 1495-an onerous heritage among the blessings and countless commodities that followed in the wake of the comparatively simple exploration of the Western
Hemisphere 11" There may not be a man in the moon, nor life but we ought to act as though there were.
on
Mars,
NEAR RETIRING
IN its own modest words, this Nuffield study3 is a "minor contribution to fuller understanding of the problems of ageing among manual workers in industry ". Based on interviews with older men employed in Slough factories, it reports the kind of jobs they were doing, their subjective experience of strain at work, the foremen’s attitudes towards them, and changes of job in later working life. Though the material consists more of impressions than facts, the style is readable, the conclusions are cautious, and useful suggestions are made for more precise and detailed studies. Though nothing very new emerges, this succinct statement of the problems of an ageing labour force is valuable in a period of rapidly increasing industrial technology. In particular, the report brings out the opinions and attitudes of older workers themselves and shows how few give any serious consideration to the impact retirement will make on their lives. Work involving time-stress again appears as the main difficulty of older workers, and the report confirms the finding from other studies that men in paced jobs often move in middle age to relatively unskilled tasks which offer opportunities for self-regulation of speed of work. On the whole, foremen seem to be helpful and understanding about adjustments of this kind, and indeed to show foresight inasmuch as they try to move older men to suitable work before they break down. By these internal transfers industry can reduce the casualty-rate among its own employees, but in the favourable employment conditions of Slough the older men were prepared to search for more attractive jobs elsewhere and to make a success of them; furthermore, supervisors did not seem to be unduly prejudiced in their attitudes to older workers. Any report that draws attention to the need for a preventive approach to ageing in industry is to be welcomed. Though a good deal is now known about what to expect in groups of men reaching middle age in certain kinds of work, industry itself seems to have a low awareness of this knowledge and how to apply it; and people in responsible positions in management and labour could read this study with profit. It prompts a further thought. How does
ageing affect
1. Rumball, A., Acheson, E. D. Brit. med. J. Feb. 16, 1963, p. 423. 2. N.Y. St. J. Med. 1963, 63, 1310. 3. Workers Nearing Retirement. Nuffield Foundation, Nuffield Lodge, Regent’s Park, London, N.W.1. 1963. Pp. 53. 5s.
medical occupations today ? So far, little seems to be known about time-stress and fatigue in older doctors. Some information about the attitudes to, and use of, retirement by physicians might help us to decide whether the retirement policy in the health service is sound. We also need information on the most suitable occupations for doctors in their late sixties. Perhaps the Nuffield Foundation will provide us with some of the answers in a future study in this series.
SALT-POISONING IN INFANCY
DANGEROUS salt retention in infancy may result from injudicious intravenous therapy, and troublesome salt retention may result from the use of corticosteroids. Accidental salt-poisoning must be very rare, and we are indebted to three Baltimore workersI for an account of a serious incident in a newborn nursery, in which salt was put into the infants’ feeds in place of sugar. 14 infants received the salt-containing feeds, and 6 of them died5 of them before the condition was recognised. Symptoms developed in 11. All had convulsions or twitching, and all became feverish. All but 1 vomited. 5 showed respiratory distress, with tachypnoea and flaring of the alae nasi. All showed intense thirst until they became seriously ill. In the 5 cases where necropsy was carried out this revealed a haemorrhagic encephalopathy, with severe capillary and venous congestion, subarachnoid and parenchymatous haemorrhages, and sinus thromboses. 4 of the patients were treated by peritoneal dialysis, followed by low-electrolyte oral feeds, and 3 of these survived. The highest serum-sodium recorded was 274 mEq. per litre, and this child survived. Prolonged hypernatrasmia is known to damage the brain, and children with inadequately treated nephrogenic diabetes insipidus, in which hypernatrsemia is a feature, undergo mental deterioration. A form of hypernatrxmic mental deficiency has been described. Consequently it is noteworthy that all the survivors of this episode are apparently physically and mentally normal. This is not the first time that infants’ feeds have been poisoned by a substance accidentally added in place of sugar, and it is valuable that we should be reminded of the fact. Perhaps we should add immunity to accidental poisoning of this nature to the list of advantages of
breast-feeding. INGROWING TOENAILS
SURGERY is never so meddlesome as in the treatment of ingrowing toenails. The accolade of the aspiring orthopaedic surgeon seems to depend on his ingenuity in devising a new operation for this common affliction. Yet, properly handled, ingrowing toenails scarcely ever need operative treatment. Lloyd-Davies and Brill2 say that the policy of the toe clinic at St. Thomas’s Hospital is primarily conservative, but that many patients arrive after their nails have already been avulsed in the casualty department. The drawback to operative treatment is that, for a short time afterwards, the patient is disabled from walking, and that often he has to hobble about in slippers or split shoes for some time. A new nail takes about six months to grow, and the end-result of operation nearly always leaves an unsightly toe. 1. 2.
Finberg, L., Kiley, J., Luttrell, C. N. J. Amer. med. Ass. 1963, 184, Lloyd-Davies, R. W., Brill, G. C. Brit. J. Surg. 1963, 50, 592.
187.
Annotations
Buyers
are
recommended
to
carry out
periodic
checks
incoming milk; and the other Milk Marketing Boards should consider introducing a system of price penalties for milk found to contain antibiotics, on the lines proposed on
ANTIBIOTICS IN MILK
ANTIBIOTICS are much used in the treatment of mastitis in cows, and traces of them are present in the animal’s milk for some days after treatment. In January, 1960, the Milk Hygiene Subcommittee of the Milk and Milk Products Technical Advisory Committee decided to undertake a survey to determine how much penicillin and other antibiotics were getting into milk in Britain. The findings are given in a reportI published last week. The survey started in January, 1961, in England and Wales, and in February, 1961, in Scotland and continued in each case for twelve months. Milk was sampled and tested at 51 centres in England and Wales and 5 in Scotland, the centres being selected to provide a representative sample of milk from each area. Penicillin was the antibiotic most commonly found. In England and Wales over 41,700 samples were examined during the year, and 11%, representing 14% of the total milk sampled, contained antibiotics. The lowest incidence (7-7%) was found in October and the highest (16.6%), in January. In Scotland, out of over 2700 samples, 99% (11-6% of the milk sampled) contained antibiotics. The lowest incidence (4-7%) was found in July, and the highest (13-8%) in May. The view of the medical advisers on the Antibiotics in Milk Panel of the Ministry of Health is that the presence in milk of any antibiotic is undesirable because of the possible ill effects on the health of a few individuals in the population. Firstly, there is the danger that the consumption of small quantities of antibiotics may sensitise some people, rendering them liable to severe reaction if therapeutic doses of these drugs are required later. Secondly, there is the danger of allergic reaction, particularly skin rashes, in a few people who are already highly reactive to penicillin. Thirdly, as a result of treatment with penicillin, strains of penicillin-resistant staphylococci that cause bovine mastitis are alleged to be increasingly common and there is a danger that any illness such organisms may cause in man will not respond to treatment with penicillin. The report recommends that manufacturers of antibiotics should be asked to provide formulations suitable for the treatment of most cases of mastitis and having an excretion-time of less than 48 hours; and that manufacturers should label their preparations to show the minimum length of time that milk from treated animals should be withheld. Veterinary surgeons could help to reduce the amount of antibiotics likely to be present in milk by restricting the quantity they leave with farmers. They could also impress upon farmers the importance of keeping back milk from treated animals for the period stated on the label. Notification to the buyer that antibiotic treatment had been given would also be helpful, since it would enable a check to be kept on milk from that farm. The British Veterinary Association has been asked informally whether its members would cooperate in this way and has indicated that it could not agree with the suggestion regarding notification which would, in its view, be a breach of professional etiquette. The Association has agreed, however, to do everything possible to see that farmers are reminded of their obligations with regard to disposal of milk from treated animals. 1. Antibiotics in Milk in Great Britain. Is. 3d.
H.M.
Stationery
Office.
Pp.
10.
the Scottish Milk Marketing Board. Food and drugs authorities should be encouraged to sample and test ex-farm milk for the presence of antibiotics and to take appropriate action. The subcommittee would also like to see a publicity campaign to ensure that producers are constantly reminded of the necessity to observe all precautions in order that the milk supply shall be free from traces of antibiotics.
by
SIC TRANSIT
WE have probably witnessed the last major experiment in simple orbital flight, which may be expected to become part of the training syllabus for astronauts and technicians rather than the goal. The next phase, already begun by Russia, is to prove the means of rendezvous in flight and the transfer of men and stores from one orbiting vehicle to another-matters which are mainly technological. Beyond is the prospect of the habitable artificial satellite, from which to launch true Space travel; and there are many uncertainties upon the health, welfare, and safety of the men who will one day set out to explore the infinite. Some of these uncertainties have to do with what are, broadly speaking, physiological factors: the consequences to the circulatory, muscular, and nervous systems of prolonged weightlessness and inactivity; how to maintain body metabolism for months when storage space is severely restricted; by what means to provide for respiratory exchange and to control the environment of temperature, pressure, and humidity; and how to limit exposure to ionising radiations. Some of the uncertain factors are both physiological and psychological: the effects of disorientation during manoeuvre; the clouding of consciousness when normal stimuli are suspended; fear of the unknown, as time slowly passes in isolation. All these we now recognise to be the preoccupations of Space medicine; but when long voyages are undertaken, older and less esoteric complications will be encountered. As the astronaut loses his exclusiveness, becoming one of a small crew, there will be the personality clashes inevitable among men under constant stress at very close quarters. There will also be the risk of illness, which could, as in the long voyages of exploration in the days of sail, bring disaster on a well-found enterprise. An attack of infectious hepatitis, for example, between Earth and Mars, is unpleasant to contemplate, and the disease is not so rare that the possibility can be ignored. It is, indeed, the infectious diseases of viral origin which seem the most difficult to provide against, partly because they are not easy to treat and partly because the incubation period is generally long. A month’s complete isolation before the launching would be a tedious start.
Sudden incapacitating illness-for example, coronary thrombosis-as a cause of aircraft accidents is always in the mind of those who investigate unexplained crashes. As a rule, it has to be set down as one of several possibilities, because there is no evidence either way; for disasters to aircraft with a single pilot are nearly always catastrophic. Though in a young, fit population the risk must be small compared with the occupational physiological hazards such as anoxia, it is real enough to direct the interest of those responsible for the care of aviators
1251
towards means of detecting latent coronary heart-disease 1; and this is an obvious approach for the screening of astronauts, who are subjected to every possible physiological investigation before selection and before each flight. Infectious disease is hardly a hazard to aviators whose flights, compared with incubation periods, are exceedingly brief; but on two counts it must now enter the reckoning of Space medicine: first because it can affect the astronaut in transit; and secondly because it is " It an undesirable export. In the words of Generales: would be well to recall that the medical profession has still not eradicated syphilis since its introduction into Europe about 1493 and the explosive epidemic of Naples in 1495-an onerous heritage among the blessings and countless commodities that followed in the wake of the comparatively simple exploration of the Western
Hemisphere 11" There may not be a man in the moon, nor life but we ought to act as though there were.
on
Mars,
NEAR RETIRING
IN its own modest words, this Nuffield study3 is a "minor contribution to fuller understanding of the problems of ageing among manual workers in industry ". Based on interviews with older men employed in Slough factories, it reports the kind of jobs they were doing, their subjective experience of strain at work, the foremen’s attitudes towards them, and changes of job in later working life. Though the material consists more of impressions than facts, the style is readable, the conclusions are cautious, and useful suggestions are made for more precise and detailed studies. Though nothing very new emerges, this succinct statement of the problems of an ageing labour force is valuable in a period of rapidly increasing industrial technology. In particular, the report brings out the opinions and attitudes of older workers themselves and shows how few give any serious consideration to the impact retirement will make on their lives. Work involving time-stress again appears as the main difficulty of older workers, and the report confirms the finding from other studies that men in paced jobs often move in middle age to relatively unskilled tasks which offer opportunities for self-regulation of speed of work. On the whole, foremen seem to be helpful and understanding about adjustments of this kind, and indeed to show foresight inasmuch as they try to move older men to suitable work before they break down. By these internal transfers industry can reduce the casualty-rate among its own employees, but in the favourable employment conditions of Slough the older men were prepared to search for more attractive jobs elsewhere and to make a success of them; furthermore, supervisors did not seem to be unduly prejudiced in their attitudes to older workers. Any report that draws attention to the need for a preventive approach to ageing in industry is to be welcomed. Though a good deal is now known about what to expect in groups of men reaching middle age in certain kinds of work, industry itself seems to have a low awareness of this knowledge and how to apply it; and people in responsible positions in management and labour could read this study with profit. It prompts a further thought. How does
ageing affect
1. Rumball, A., Acheson, E. D. Brit. med. J. Feb. 16, 1963, p. 423. 2. N.Y. St. J. Med. 1963, 63, 1310. 3. Workers Nearing Retirement. Nuffield Foundation, Nuffield Lodge, Regent’s Park, London, N.W.1. 1963. Pp. 53. 5s.
medical occupations today ? So far, little seems to be known about time-stress and fatigue in older doctors. Some information about the attitudes to, and use of, retirement by physicians might help us to decide whether the retirement policy in the health service is sound. We also need information on the most suitable occupations for doctors in their late sixties. Perhaps the Nuffield Foundation will provide us with some of the answers in a future study in this series.
SALT-POISONING IN INFANCY
DANGEROUS salt retention in infancy may result from injudicious intravenous therapy, and troublesome salt retention may result from the use of corticosteroids. Accidental salt-poisoning must be very rare, and we are indebted to three Baltimore workersI for an account of a serious incident in a newborn nursery, in which salt was put into the infants’ feeds in place of sugar. 14 infants received the salt-containing feeds, and 6 of them died5 of them before the condition was recognised. Symptoms developed in 11. All had convulsions or twitching, and all became feverish. All but 1 vomited. 5 showed respiratory distress, with tachypnoea and flaring of the alae nasi. All showed intense thirst until they became seriously ill. In the 5 cases where necropsy was carried out this revealed a haemorrhagic encephalopathy, with severe capillary and venous congestion, subarachnoid and parenchymatous haemorrhages, and sinus thromboses. 4 of the patients were treated by peritoneal dialysis, followed by low-electrolyte oral feeds, and 3 of these survived. The highest serum-sodium recorded was 274 mEq. per litre, and this child survived. Prolonged hypernatrasmia is known to damage the brain, and children with inadequately treated nephrogenic diabetes insipidus, in which hypernatrsemia is a feature, undergo mental deterioration. A form of hypernatrxmic mental deficiency has been described. Consequently it is noteworthy that all the survivors of this episode are apparently physically and mentally normal. This is not the first time that infants’ feeds have been poisoned by a substance accidentally added in place of sugar, and it is valuable that we should be reminded of the fact. Perhaps we should add immunity to accidental poisoning of this nature to the list of advantages of
breast-feeding. INGROWING TOENAILS
SURGERY is never so meddlesome as in the treatment of ingrowing toenails. The accolade of the aspiring orthopaedic surgeon seems to depend on his ingenuity in devising a new operation for this common affliction. Yet, properly handled, ingrowing toenails scarcely ever need operative treatment. Lloyd-Davies and Brill2 say that the policy of the toe clinic at St. Thomas’s Hospital is primarily conservative, but that many patients arrive after their nails have already been avulsed in the casualty department. The drawback to operative treatment is that, for a short time afterwards, the patient is disabled from walking, and that often he has to hobble about in slippers or split shoes for some time. A new nail takes about six months to grow, and the end-result of operation nearly always leaves an unsightly toe. 1. 2.
Finberg, L., Kiley, J., Luttrell, C. N. J. Amer. med. Ass. 1963, 184, Lloyd-Davies, R. W., Brill, G. C. Brit. J. Surg. 1963, 50, 592.
187.