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SYNTHETIC CREAM
173
THE LANCET LONDON:: SATURDAY, FEBRUARY 7,1942
SYNTHETIC CREAM
hit the summer and autumn of last year there were several large outbreaks of paratyphoid fever, notably in the urban areas of Birmingham,1 Liverpooland Bristol.3 In most of these synthetic cream was the proved or suspected vehicle of spread, and as a result this new ersatz luxury in our diet came, and still is, under considerable suspicion. Synthetic cream as now made by reputable firms-mostly in the London area-is a mixture of flour, dried egg-yolk, sugar and water with a vegetable fat, usually ground-nut oil. The flour and water paste is heated to 210° F. for 30 minutes and then cooled ; the egg-yolk powder and sugar are added ; the fat is melted separately, held at 14° F. and atomised under high pressure into the starchy paste. The whole mixture is further heated at 160-170° F. for 30 minutes, homogenised, and then cooled to 40° F. over brine coolers. It is finally piped mechanically into new but unsterilised tins, the lids of which are pressed on by hand and tightened by a mechanical expanding tool. Obviously there is no guarantee that the synthetic cream may not become contaminated at the manufacturing plant but the pasteurisation of the mixture and the largely mechanical handling reduces this risk very considerably. Further, the widespread epidemics naturally brought suspicion on the manufacturers, who as a result have taken additional precautions which usually include a regular bacteriological test of their products. Their premises must also conform with the requirements of the new Food and Drugs Act, but as an additional precaution it might be advisable to license all makers of this now popular product. There is a risk of contamination en route from manufacturer to retailer or bakery, but the most likely locus of infection is the bakery, often a large to establishment supplying bread and in risk of cream retail the area. Here the shops many becoming infected by human handlers is much greater than at the factory, and here- in fact the epidemiologist has mostly fixed the blame for the recent outbreaks. WARIN/ in his report of three outbreaks in the Birmingham area, concluded that the infection always originated in one or other bakery and not at the manufacturer’s ; no other reasonable explanation fitted the epidemiological data, for cream from the same factories was being distributed to many other areas which remained free of paratyphoid. Bakehouses have not always established a good reputation for maintaining the high standard of general and personal hygiene which the handling of contaminable foodstuffs demands, and cream, whether natural or synthetic, has ’been incriminated as the vehicle in many outbreaks of intestinal infections, large and small. The chance of foodstuffs becoming contaminated by human carriers of an intestinal pathogen is greatest if the disease is of a kind which includes among its victims a proportion of mild infections and
confectionery
1. Warin, J. F. Med. Offr, Jan. 17, 1942, p. 21. 2. Holt, H. D., Vaughan, A. C. T. and Wright, H. D. Lancet, Jan. 31, 1942, p. 133. 3. Davies, I. G., Cooper, K. E. and Fleming, D. S. Ibid, p. 129.
transient carriers who continue at work while excreting the organism. Paratyphoid is now, probably more than some years ago, such an infection-for example, in the recent epidemics the fatality ranged from 0-8% at Bristol and just over 1% in Liverpool to 3’5% in one of the Birmingham outbreaks. For the discovery of the carrier or ambulant case, the Widal test is not now regarded as wholly reliable, for transient carriers may not show any specific antibodies in the blood. However, it may still be a infected useful preliminary examination in a of workers. In a staff Birmingpersons among large ham outbreak, of a staff of 91 whose bloods were tested, 13 gave positive Widal tests and 6 of these were found to be excreting paratyphoid bacilli ; in 10 excretors were found 53 Liverpool among persons with positive Widal tests (out of some 200 examined at a bakery). The important, point is that only 3 of these 23 excretors were clinically ill. In the Bristol outbreak the source of infection was ascribed to a girl who did not develop a clinical attack of paratyphoid until 3-4 weeks after she had infected the cream. Thus, when paratyphoid is endemic in an area, and conditions are suitable. for epidemic spread, any large establishment may have its quota of transient carriers and ambulant cases ; if that establishment is concerned in the distribution of foodstuffs, the chance of its being a focus of spread becomes considerable. Prevention must be largely directed to raising the standard of personal hygiene among the personnel of any business concerned in the handling of food, particularly cooked or prepared foods and milk. The new Food and Drugs Act which came into force in 1939 requires the installation of washhand basins, towels and soap in all such premises. The MOH through his sanitary inspector, in amicable cooperation with the managerial staff, must educate the handlers of foodstuffs in the attendant dangers and their mode of He will find much practical advice on this in the review written by the late W. M. SCOTT4 subject than whom no-one was better qualified to give it.
tracking
prevention.
THE INTERNAL CARTILAGE THE internal semilunar cartilage is always a common offender, but particularly so in war-time when knees are exposed to unaccustomed strains, and the busy surgeon may save his time by pausing to question his diagnostic criteria and assess the rationale of his treatment. CRAVENER and MACELRoy,5 surveying some 1700 cases, emphasise that the prognosis is really determined by whether the injury involves the vascular periphery of the cartilage or the avascular central portion. If the tear is in the former situation, as it is in of cases, healing by fibrous tissue will follow strict immobilisation ; in the remaining 45% it will lead to non-union with persistence of symptoms. In their series 43% of the injuries were in the region of the anterior horn and anterior cruciate ligament, and 41%were simple or complex bucket-handle tears, while the posterior horn was affected in only 7-5% ; some degree of dislocation occurred in 24-5% of the total, and mainly of the anterior end. Clinically the most important diagnostic symptoms were found to be pain, instability and intermittent swelling ; looking was reported in less than a third of the cases and could not be regarded as an essential part of the picture.
55%
4. Scott, W. M. Ibid, 1941, ii, 389. 5. Cravener, E. K., MacElroy, D. G. J. Amer. med.Ass. 1941, 117,1695.
THE LANCET LONDON:: SATURDAY, FEBRUARY 7,1942
SYNTHETIC CREAM
hit the summer and autumn of last year there were several large outbreaks of paratyphoid fever, notably in the urban areas of Birmingham,1 Liverpooland Bristol.3 In most of these synthetic cream was the proved or suspected vehicle of spread, and as a result this new ersatz luxury in our diet came, and still is, under considerable suspicion. Synthetic cream as now made by reputable firms-mostly in the London area-is a mixture of flour, dried egg-yolk, sugar and water with a vegetable fat, usually ground-nut oil. The flour and water paste is heated to 210° F. for 30 minutes and then cooled ; the egg-yolk powder and sugar are added ; the fat is melted separately, held at 14° F. and atomised under high pressure into the starchy paste. The whole mixture is further heated at 160-170° F. for 30 minutes, homogenised, and then cooled to 40° F. over brine coolers. It is finally piped mechanically into new but unsterilised tins, the lids of which are pressed on by hand and tightened by a mechanical expanding tool. Obviously there is no guarantee that the synthetic cream may not become contaminated at the manufacturing plant but the pasteurisation of the mixture and the largely mechanical handling reduces this risk very considerably. Further, the widespread epidemics naturally brought suspicion on the manufacturers, who as a result have taken additional precautions which usually include a regular bacteriological test of their products. Their premises must also conform with the requirements of the new Food and Drugs Act, but as an additional precaution it might be advisable to license all makers of this now popular product. There is a risk of contamination en route from manufacturer to retailer or bakery, but the most likely locus of infection is the bakery, often a large to establishment supplying bread and in risk of cream retail the area. Here the shops many becoming infected by human handlers is much greater than at the factory, and here- in fact the epidemiologist has mostly fixed the blame for the recent outbreaks. WARIN/ in his report of three outbreaks in the Birmingham area, concluded that the infection always originated in one or other bakery and not at the manufacturer’s ; no other reasonable explanation fitted the epidemiological data, for cream from the same factories was being distributed to many other areas which remained free of paratyphoid. Bakehouses have not always established a good reputation for maintaining the high standard of general and personal hygiene which the handling of contaminable foodstuffs demands, and cream, whether natural or synthetic, has ’been incriminated as the vehicle in many outbreaks of intestinal infections, large and small. The chance of foodstuffs becoming contaminated by human carriers of an intestinal pathogen is greatest if the disease is of a kind which includes among its victims a proportion of mild infections and
confectionery
1. Warin, J. F. Med. Offr, Jan. 17, 1942, p. 21. 2. Holt, H. D., Vaughan, A. C. T. and Wright, H. D. Lancet, Jan. 31, 1942, p. 133. 3. Davies, I. G., Cooper, K. E. and Fleming, D. S. Ibid, p. 129.
transient carriers who continue at work while excreting the organism. Paratyphoid is now, probably more than some years ago, such an infection-for example, in the recent epidemics the fatality ranged from 0-8% at Bristol and just over 1% in Liverpool to 3’5% in one of the Birmingham outbreaks. For the discovery of the carrier or ambulant case, the Widal test is not now regarded as wholly reliable, for transient carriers may not show any specific antibodies in the blood. However, it may still be a infected useful preliminary examination in a of workers. In a staff Birmingpersons among large ham outbreak, of a staff of 91 whose bloods were tested, 13 gave positive Widal tests and 6 of these were found to be excreting paratyphoid bacilli ; in 10 excretors were found 53 Liverpool among persons with positive Widal tests (out of some 200 examined at a bakery). The important, point is that only 3 of these 23 excretors were clinically ill. In the Bristol outbreak the source of infection was ascribed to a girl who did not develop a clinical attack of paratyphoid until 3-4 weeks after she had infected the cream. Thus, when paratyphoid is endemic in an area, and conditions are suitable. for epidemic spread, any large establishment may have its quota of transient carriers and ambulant cases ; if that establishment is concerned in the distribution of foodstuffs, the chance of its being a focus of spread becomes considerable. Prevention must be largely directed to raising the standard of personal hygiene among the personnel of any business concerned in the handling of food, particularly cooked or prepared foods and milk. The new Food and Drugs Act which came into force in 1939 requires the installation of washhand basins, towels and soap in all such premises. The MOH through his sanitary inspector, in amicable cooperation with the managerial staff, must educate the handlers of foodstuffs in the attendant dangers and their mode of He will find much practical advice on this in the review written by the late W. M. SCOTT4 subject than whom no-one was better qualified to give it.
tracking
prevention.
THE INTERNAL CARTILAGE THE internal semilunar cartilage is always a common offender, but particularly so in war-time when knees are exposed to unaccustomed strains, and the busy surgeon may save his time by pausing to question his diagnostic criteria and assess the rationale of his treatment. CRAVENER and MACELRoy,5 surveying some 1700 cases, emphasise that the prognosis is really determined by whether the injury involves the vascular periphery of the cartilage or the avascular central portion. If the tear is in the former situation, as it is in of cases, healing by fibrous tissue will follow strict immobilisation ; in the remaining 45% it will lead to non-union with persistence of symptoms. In their series 43% of the injuries were in the region of the anterior horn and anterior cruciate ligament, and 41%were simple or complex bucket-handle tears, while the posterior horn was affected in only 7-5% ; some degree of dislocation occurred in 24-5% of the total, and mainly of the anterior end. Clinically the most important diagnostic symptoms were found to be pain, instability and intermittent swelling ; looking was reported in less than a third of the cases and could not be regarded as an essential part of the picture.
55%
4. Scott, W. M. Ibid, 1941, ii, 389. 5. Cravener, E. K., MacElroy, D. G. J. Amer. med.Ass. 1941, 117,1695.