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The use of dried milk at infants' milk depots
1910.
PUIILIC IINAL TI:I.
among the non-scarlatinal convalescents during that time. (It is hardly necessary to remark that convalescent are sent to Campie only after they are presumably quite free from infection.) This might be taken as indicating that under the conditions at Campie--good ventilation, adequate cubic space and sufficient separation in dormitories--the infectivity of those 25 cases remains in abeyance, to be lit up afresh on their return to less hygienic conditions at home. It must, however, be noted that the nonscarlatinat population at Campie is probably not particularly susceptible to scarlatinal infection. For administrative reasons children under six years o f age are not admitted, and a fair proportion of the inmates are adolescents and young adults convalescent from diphtheria and typhoid, many of whom may have been protected by a previous attack of scarlatina. On the figures obtained from this series of cases I base the following conclusions :-I. That the return case incidence is unduly heavy on the first five years of life. 2. That the case mortality of return cases is practically the same as that o f " all scarlatina." 3. That the more specially infectious complications of scarlatina--otorrhcea, rhinorrhcea, and adenitis--are more frequent in both infecting and return cases than in "all scarlatina." 4. That a certain proportion of so-called return cases are really due to coincidence. 5. That the return to insanitary home conditions may in some cases be the cause of recrudence of infection in a patient who was not infectious when leaving hospital. I have to thank Dr. C. B. Ker, medical superintendent of the Edinburgh City Hospital, for permission to publish these results. REFERENCES.
1. " Allbutt's System of Medicine," vol. 2, part i, 19o6. 2. Brit. Med. Journ., September 3rd, 1898. 3- Report to M.A.B., 19o4. 4. Hospitalstide~de,March I4th, 19o8 (q~o~ed). Semaine Mddicale, June 2oth, 19o6. 5. Report to M.A.B., PUBLIC HEALTH, October, I9O6. 6. Berl. Klilz. Woch., June 2Ist, 19o 9. 7. Report to M.A.B., 19o4. 8. PUBLIC HEALTH, October, 19o6. 9. The Hospital, November I7th , 19o6. IO. " Fisk Fund Prize Dissertation " (Providence, U.S.A.), 19o 9 . II. PUBLIC HEALTH, August, 19o4,
325
T H E U S E O F D R I E D M I L K AT I N F A N T S ' M I L K DEPOTS.*' By C. KILLICK MILLARD, M.D., D.Sc., Medical Officer of Health, Leicester.
T n,:
increasing use which is being made of dried milk as a food for infants makes the question of its use at infants' milk depots one of special interest to medical officers of health. At the Leicester Infants' Milk Depot dried milk has almost entirely superseded humanized milk, and the results obtained have been very satisfactory. As this change in our practice is of rather a fundamental character, it will be well to consider the advantages and disadvantages of dried milk in detail. The dried milk used in the Leicester Depot is milk dried by the following process. In this process a thin film of milk is passed over a revolving metal cylinder heated by steam to a temperature considerably above the boiling point (say 250 F.). The temperature being so high and the film of milk very thin, the greater part of moisture in the milk is rapidly dissipated, what remains being afterwards taken up by the milksugar as water of crystallization. The film of dried milk is automatically separated by a knife-edge as the cylinder revolves, and is collected in a receptacle below. The process is beautifully simple, and, owing to the duration of the heating process being, so extremely short, the composition of the milk solids' is altered comparatively little--a very important point. Dried milk as thus obtained is a coarse, granular, cream-coloured powder, easily miscible with water, in which the greater part o f it readily dissolves. The relative proportion of fat, proteids, and lactose remain the same as in the original milk. After reconstitution as liquid milk by the addition of water the consistency, colour, and taste are all found to be somewhat modified, and the fat rises more readily to the surface, owing to the cream globules being ruptured. It is by no means unpalatable, but is not very suitable for use with tea or coffee. As a food for infants it has one outstanding and all-important advantage, viz., that it is more easily retained--i.e., is more digestible-than fresh cows' milk. Possibly this is due to the fact that it does not tend to form a hard cheesy curd in the stomach, as is so often t h e case with the latter. It is only necessary to try dried milk in a few cases of infants who are sick after almost every * React before the Midland Branch of the Society of Medical Officers of Health, February 3rd, I9to.
326
PUBLIC HEAZTH.
meal and making little or no progress, to satisfy oneself of the value of dried milk. The improvement is often very striking: the child takes to the milk at once, ceases to be sick, and puts on weight more rapidly. The mothers are usually so pleased with dried milk and find it so convenient that it is rarely they wish to return to the humanized milk. Another important advantage possessed by milk dried by the process I have described is that the temperature to which it is submitted in the process of manufacture has been proved experimentally to destroy tubercle bacilli. Yet another advantage, especially during the hot months of summer, is that so long as it remains in its desiccated state it will keep good almost indefinitely. Packed in air-tight tins, samples have been sent round the world. Moreover, if the precaution is observed--as it always should b e - - o f only preparing each feed as required, the ever-present danger in the case of ordinary milk of contamination by flies is entirely obviated. For this reason dried milk specially commends itself as a preventive of epidemic diarrhoea. Hitherto almost all existing infants' milk depots in this country have adopted the gou#e de lait principle, a n d supply milk modified by the addition of water, cream, and~sugar--i.e., " humanized " - - and dispensed in separate bottles for each feed, the amount and strength varying according to the age of the child. This method certainly has several advantages over the ordinary method of infant feeding in that it secures uniformity and regularity and safeguards the infant against an ignorant or careless mother, as well as against bacterial contamination. One of its chief drawbacks, however, is the great expense involved. In the first place, the installation of special machinery is necessary, involving considerable capital outlay ; but more serious is the continuous expenditure entailed by the large amount of labour required for the process of bottling and washing of bottles, and the heavy loss incurred on broken bottles. Owing to this it is, I believe, t h e experience of all depots conducted on this principle that the milk has to be sold considerably below cost price if it is to be kept within reach of the poor, for whom it is primarily intended. Another drawback exists, too, in the necessity for the milk being fetched (or delivered) from the depot daily. Poor people living at a distance often find this difficulty insuperable, and hence the depot can only supply, so far as the poor are concerned, a
JUNE,
comparatively small area in its immediate vicinity. Those who are better off, however-even though living at a distance--can afford to pay extra to have the milk fetched or delivered, and thus the benefits of a depot tend to some extent to be diverted to a class who do not really require a subsidized milk supply. If, however, branch depots are opened all over a t'own the expense is, of course, still further increased, and is apt to become prohibitive. With dried milk the financial difficulty is largely got over. As there is no labour in bottling or washing of bottles, and no loss on broken bottles, dried milk can be sold at cost price, and yet still be within reach of the p o o r - i.e., it need not cost more than ordinary milk. The only loss, then, incurred is the cost of upkeep of the depot. Moreover, as a week's supply or more can be purchased at a time the diffÉculty of fetching the milk daily does not exist, and one centrally placed depot can supply the whole of an ordinary provincial town. In Leicester when we supplied humanized milk on thegoutte de laitprinciple our depot cost nearly ~3oo a year, whereas now that we have practically abandoned the humanized milk and adopted dried milk the net cost will only be about a third of that sum. The fact that in the case of an infants' milk depot started de novo for dried milk only no capital outlay on machinery is necessary, makes the provision of an infants' milk depot in a small district a comparatively easy matter. Dried Milk v. Patent Foods.--One reason why dried milk is so popular with the mother is because it possesses all the convenience of the " p a t e n t " food made from cereals. Indeed, they like to refer to it as a "food," rather than as milk. Yet it is evident that the serious objection to the use of patent foods of the class referred to--viz., that they tend more or less to supplement milk in the infant dietary--does not apply to a " f o o d " which, after all, is milk. It is possible that dried milk may help largely to oust these proprietary foods, with great benefit to our infant population. It now remains to consider the objections to dried milk as a food for infants. The immed i a t e and palpable effects of substituting dried milk for fresh milk is in many cases, as has been said, distinctly beneficial. Is there any danger, however, that the ultimate effect of its prolonged use may be detrimental? At first, it must be confessed, the writer was rather apprehensive that the dangers supposed to lie in the use of sterilized milk would exist
PUBLIC HEALTH.
1910.
fortiori in dried milk, and t h a t a t e n d e n c y to the
m o r b i d condition often referred to as "scurvy- r i c k e t s " m i g h t sooner or later m a n i f e s t itself. Before going further, it m a y be observed t h a t the highest authorities now deprecate the t e r m " scurvy rickets," as really indicative of two distinct conditions, which, t h o u g h t h e y m a y co-exist, h a v e an entirely different etiology. S c u r v y is believed to be chiefly due to a lack of a n t i - s c o r b u t i c p r o p e r t i e s ( w h a t e v e r their n a t u r e m a y be) in the food ; whilst the essential factor in the c a u s a t i o n of rickets is n o w believed to be a deficiency of fat in the infant dietary. I f this view is correct, t h e r e is not m u c h need to fear t h a t t h e use of dried milk will produce rickets, providing t h e p r o p o r t i o n of fat is not diminished. As regards scurvy, however, the case is different, for it is reasonable to suppose t h a t the a n t i - s c o r b u t i c properties in dried milk will be affected. I t is a question, therefore, for experience to decide, and from the outset I have k e p t careful look-out for a n y u n t o w a r d s y m p t o m s . W e h a v e n o w used dried milk at the Leicester milk d e p o t for s o m e t h i n g like 4oo infants, a n d for periods r a n g i n g f r o m a few weeks up to ten or twelve m o n t h s . I n addition to seeing m o s t of t h e cases personally from t i m e to time, I have m a d e inquiries f r o m fifteen m e d i c a l m e n p r a c t i s i n g in the districts whence m o s t of the cases are drawn, and inquiries have also been m a d e f r o m the m o t h e r s s u b s e q u e n t to the infant h a v i n g been t a k e n off the d e p o t ; but in no i n s t a n c e have a n y cases been discovered in which t h e r e was reason to t h i n k t h a t t h e p r o l o n g e d use of dried milk had been detrimental. DISCUSSION. DR. BOSTOCK HILL prefaced his opening of the discussion by thanking Dr. Miltard for his excellent paper, which, he said, was one of great value, dealing as it did with a question of much interest to medical officers of health. H e had always urged the use of sterilized milk as a means of remedying the present defects of dealing with the mitk supply, and he was pleased to have the corroboration of Dr. Millard. H e was convinced, from constant observation, that there was no danger from the use of sterilized milk; but he did not think that the milk should be heated beyond lO4 deg., as the constant use of superheated milk would be prejudicial. One point to be urged for the use of dried milk was that it would satisfy the yearnings of the average mother to give the child some form of solid food.~ H e laid particular stress upon the fact that the use of dried milk would do away with the use of artificial foods, upon the worst types of which a great
327
many hand-fed children were brought up. T h e r e are certain kinds of artificial foods in general use which are very prejudicial to the health of infants, he said, and if we can get the mothers to use dried milk in preference to these artificial foods it would be an advance in infant feeding. DR. t3ARWISE said that he could bear eloquent testimony to the investigations made by Dr. Millard. Dried milk certainly had another advantage which Dr. Millard had not mentioned, and that was that in India and Ceylon, where there is no milk to be had at certain periods of the year, dried milk would be invaluable. DR. ROBERTSON said that he had an open mind on the question of dried milk, but he still had a preference for fresh milk. T h e reason of his hesitation in advocating the use of dried milk was that there was a large amount of evidence in regard to the production of rickets as the result of feeding not only babies but adults on things that were not fresh, and he thought probably all of . them would agree that where we could get clean and good milk, we did not want dried milk. W e are, he said, very grateful to Dr. Miltard and medical officers of health in other towns for the testing they have done in regard to dried milk, which is very valuable. H e did not believe the giving of an imperfect food for a short time would do any baby harm, but he would ask Dr. Millard if dried milk had been used over long periods. There were one or two interesting points upon which he would like information. Dr. Millard said that tubercle bacilli were destroyed in dried milk; but he would like to know whether Dr. Millard had made this experiment himself. Dr. Millard said that the dried milk was more easily digested, and he believed that this was correct, but he did not know how it could be proved; some experiments were made which showed that in the laboratory it was more easily digested. Children who had sickness with ordinary milk would, he thought, have sickness with dried milk. Dm GARRE'rr said that this was a subject of particular interest from the fact that artificial feeding was so largely practised. It was very useful to have information concerning some new kind of milk food which could be relied upon. Personally, he thought that a great many of the arguments used against dried milk were wrong •and ill-founded ; artificial feeding coula be resorted to without success, but the fault mainly lay in the feeding being so badly done, and in the poorer classes the c~rnou~ of food was insufficient. In regard t o sterilized milk he believed that the scurvy which was met with at times was often due to insufficient feeding. A very great number of infants had been fed on sterilized milk and had done very well, and some had done very badly where there was a difficulty in getting a milk to suit them. No doubt, as Dr. Robertson said, if
328
PUBLIC HEALTH.
we had/)use fresh milk this would be best. Milk :is a very great danger in regard to tuberculosis :and other infectious diseases, such as scarlet fever, etc.; and these dangers are obviated, he said, by the use of dried milk. D m MILLARD, replying on the discussion, said that he was extremely obliged for the criticism of his paper. It was quite true that some people did not find dried milk palatable, but some did, and certainly all. babies did. Babies, he said, showed a decided preference for dried milk over fresh milk, and he believed this was becanse the former was much more easily digested. Speaking on the question of cost, he said that he used castor sugar, as he did not think it necessary to use milk sugar, and he further stated that it cost very little more to feed a baby on dried milk than on dairy milk. T h e most serious criticism, he thought, was whether one could rely upon the complete elimination of tubercle bacilli; he had not personally made experiments to prove that this was the case, though such experiments had been made. If it were true that dried milk gained immunity from tubercle bacilli this would be a gre~t advantage, as it was impossible to safeguard all fresh milk, and would do away with infants getting the seeds of consumption from the cradle. Replying to Dr. Robertson, he said that in Leicester there were possibly fifty babies who had been fed on dried milk for over nine months, a n d perhaps 2oo for over six months ; about 19o babies were being fed at the preserit time. In some cases where dried milk had not given satisfaction, fresh milk had been tried successfully, but this had not happened in many cases. THE NEGLECTOF TUBEReULOSlS.--It may hot be
inappropriate to contrast the disproportionate fear of the public as regards scarlet fever, with its comparative lack of suffering and small deathrate, to their singular apathy and carelessness in reference to tuberculosis, a disease which is also infectious but frequently entails months or years of great suffering and expense, and has a mortality higher than all the zymotic diseases put together. If this disease were called a "fever" it might receive more attention from the legislature. It is also interesting to contrast the amount of money spent out of the public funds in this country for the purpose of limiting the spread of these diseases; in Margate the approximate annual expenditure of isolating and treating patients suffering from scarlet fever, diphtheria and enteric fever is ~3,ooo~ whereas the amount of public money spent on attempting to check the spread of tuberculosis came to only about ~7 during the year, and there are no public funds available for the treatment of the disease except at the workhouse.~Assuat Re:port of Dr. Bertra:n T~orstos,
Medical Ofice*, of ttea#h, Margate.
JuicE,
UNWHOLESOME PASTEURIZED SKIMMED MILK. By CHARLES PORTER, M.D., B.Sc., M.R.C.P. Ed., Barrister-at- Law, MedicaI Officer of Health, St. Marylebone.
A S the following case refers to a m e t h o d which m a y be adopted in dealing with impure milk under the sections as to u n s o u n d food in the Public H e a l t h Acts, it has been t ~ o u g h t w o r t h while to relate it. Some time ago the Public H e a l t h C o m m i t t e e of the Metropolitan B o r o u g h of St. Marylebone i n s t r u c t e d their medical officer of health to take samples of various foods and submit t h e m for bacteriological examination to Dr. E a s t e s at tile L a b o r a t o r i e s of P a t h o l o g y and Public Health. A considerable n u m b e r of the samples taken were of milk, and amongst these was one of pasteurized skimmed milk from an itinerant v e n d o r w h o s e " w a l k " lies mainly in those poorer parts of the district affected by Jewish and other aliens. The fluid is sold at 2d. or 2}d. per quart, and is dispensed from an o r d i n a r y I I - q u a r t h a n d , c a n , which is filled from time t o time from a large c h u r n on a handcart. T h e report received regarding this miik was dated D e c e m b e r I l t h , 19o 9, and was to the effect t h a t " t h i s sample contains a distinct trace of pus, a few red blood discs, and a large n u m b e r of streptococci, which are s o m e t i m e s p h a g o c y t e & T h e a m o u n t of e x t r a n e o u s matter (vegetable and mineral) is negligible. T h e streptococci have grown vigorously in culture, and also staphylococci and some bacilli. Spores of the B. Enteritidis sporogenes are present in every IO c.c. o f the milk. Remarks : T h e milk is quite unfit for h u m a n c o n s u m p t i o n by reason of its pus content, and a p a r t from this the pasteurization has been inefficient." I m m e d i a t e l y on receipt of this report a communication was sent to t h e m a n a g i n g d i r e c t o r of the pasteurizing c o m p a n y supplying the milk, directing his a t t e n t i o n to the findings of the bacteriologist, and advising him that greater care should be exercised in the future. Communications were also sent to the medical officer of h e a l t h of the district in which the premises of the firm are situated, and to the medical officer of health of the L o n d o n C o u n t y CounCil. At the same time consideration was given to the possibility of dealing with the milk under the sections in the Public H e a l t h Act relating to unsound food, and having the milk c o n d e m n e d and d e s t r o y e d after seizure in the usual wait. T h e only possible course seemed
PUIILIC IINAL TI:I.
among the non-scarlatinal convalescents during that time. (It is hardly necessary to remark that convalescent are sent to Campie only after they are presumably quite free from infection.) This might be taken as indicating that under the conditions at Campie--good ventilation, adequate cubic space and sufficient separation in dormitories--the infectivity of those 25 cases remains in abeyance, to be lit up afresh on their return to less hygienic conditions at home. It must, however, be noted that the nonscarlatinat population at Campie is probably not particularly susceptible to scarlatinal infection. For administrative reasons children under six years o f age are not admitted, and a fair proportion of the inmates are adolescents and young adults convalescent from diphtheria and typhoid, many of whom may have been protected by a previous attack of scarlatina. On the figures obtained from this series of cases I base the following conclusions :-I. That the return case incidence is unduly heavy on the first five years of life. 2. That the case mortality of return cases is practically the same as that o f " all scarlatina." 3. That the more specially infectious complications of scarlatina--otorrhcea, rhinorrhcea, and adenitis--are more frequent in both infecting and return cases than in "all scarlatina." 4. That a certain proportion of so-called return cases are really due to coincidence. 5. That the return to insanitary home conditions may in some cases be the cause of recrudence of infection in a patient who was not infectious when leaving hospital. I have to thank Dr. C. B. Ker, medical superintendent of the Edinburgh City Hospital, for permission to publish these results. REFERENCES.
1. " Allbutt's System of Medicine," vol. 2, part i, 19o6. 2. Brit. Med. Journ., September 3rd, 1898. 3- Report to M.A.B., 19o4. 4. Hospitalstide~de,March I4th, 19o8 (q~o~ed). Semaine Mddicale, June 2oth, 19o6. 5. Report to M.A.B., PUBLIC HEALTH, October, I9O6. 6. Berl. Klilz. Woch., June 2Ist, 19o 9. 7. Report to M.A.B., 19o4. 8. PUBLIC HEALTH, October, 19o6. 9. The Hospital, November I7th , 19o6. IO. " Fisk Fund Prize Dissertation " (Providence, U.S.A.), 19o 9 . II. PUBLIC HEALTH, August, 19o4,
325
T H E U S E O F D R I E D M I L K AT I N F A N T S ' M I L K DEPOTS.*' By C. KILLICK MILLARD, M.D., D.Sc., Medical Officer of Health, Leicester.
T n,:
increasing use which is being made of dried milk as a food for infants makes the question of its use at infants' milk depots one of special interest to medical officers of health. At the Leicester Infants' Milk Depot dried milk has almost entirely superseded humanized milk, and the results obtained have been very satisfactory. As this change in our practice is of rather a fundamental character, it will be well to consider the advantages and disadvantages of dried milk in detail. The dried milk used in the Leicester Depot is milk dried by the following process. In this process a thin film of milk is passed over a revolving metal cylinder heated by steam to a temperature considerably above the boiling point (say 250 F.). The temperature being so high and the film of milk very thin, the greater part of moisture in the milk is rapidly dissipated, what remains being afterwards taken up by the milksugar as water of crystallization. The film of dried milk is automatically separated by a knife-edge as the cylinder revolves, and is collected in a receptacle below. The process is beautifully simple, and, owing to the duration of the heating process being, so extremely short, the composition of the milk solids' is altered comparatively little--a very important point. Dried milk as thus obtained is a coarse, granular, cream-coloured powder, easily miscible with water, in which the greater part o f it readily dissolves. The relative proportion of fat, proteids, and lactose remain the same as in the original milk. After reconstitution as liquid milk by the addition of water the consistency, colour, and taste are all found to be somewhat modified, and the fat rises more readily to the surface, owing to the cream globules being ruptured. It is by no means unpalatable, but is not very suitable for use with tea or coffee. As a food for infants it has one outstanding and all-important advantage, viz., that it is more easily retained--i.e., is more digestible-than fresh cows' milk. Possibly this is due to the fact that it does not tend to form a hard cheesy curd in the stomach, as is so often t h e case with the latter. It is only necessary to try dried milk in a few cases of infants who are sick after almost every * React before the Midland Branch of the Society of Medical Officers of Health, February 3rd, I9to.
326
PUBLIC HEAZTH.
meal and making little or no progress, to satisfy oneself of the value of dried milk. The improvement is often very striking: the child takes to the milk at once, ceases to be sick, and puts on weight more rapidly. The mothers are usually so pleased with dried milk and find it so convenient that it is rarely they wish to return to the humanized milk. Another important advantage possessed by milk dried by the process I have described is that the temperature to which it is submitted in the process of manufacture has been proved experimentally to destroy tubercle bacilli. Yet another advantage, especially during the hot months of summer, is that so long as it remains in its desiccated state it will keep good almost indefinitely. Packed in air-tight tins, samples have been sent round the world. Moreover, if the precaution is observed--as it always should b e - - o f only preparing each feed as required, the ever-present danger in the case of ordinary milk of contamination by flies is entirely obviated. For this reason dried milk specially commends itself as a preventive of epidemic diarrhoea. Hitherto almost all existing infants' milk depots in this country have adopted the gou#e de lait principle, a n d supply milk modified by the addition of water, cream, and~sugar--i.e., " humanized " - - and dispensed in separate bottles for each feed, the amount and strength varying according to the age of the child. This method certainly has several advantages over the ordinary method of infant feeding in that it secures uniformity and regularity and safeguards the infant against an ignorant or careless mother, as well as against bacterial contamination. One of its chief drawbacks, however, is the great expense involved. In the first place, the installation of special machinery is necessary, involving considerable capital outlay ; but more serious is the continuous expenditure entailed by the large amount of labour required for the process of bottling and washing of bottles, and the heavy loss incurred on broken bottles. Owing to this it is, I believe, t h e experience of all depots conducted on this principle that the milk has to be sold considerably below cost price if it is to be kept within reach of the poor, for whom it is primarily intended. Another drawback exists, too, in the necessity for the milk being fetched (or delivered) from the depot daily. Poor people living at a distance often find this difficulty insuperable, and hence the depot can only supply, so far as the poor are concerned, a
JUNE,
comparatively small area in its immediate vicinity. Those who are better off, however-even though living at a distance--can afford to pay extra to have the milk fetched or delivered, and thus the benefits of a depot tend to some extent to be diverted to a class who do not really require a subsidized milk supply. If, however, branch depots are opened all over a t'own the expense is, of course, still further increased, and is apt to become prohibitive. With dried milk the financial difficulty is largely got over. As there is no labour in bottling or washing of bottles, and no loss on broken bottles, dried milk can be sold at cost price, and yet still be within reach of the p o o r - i.e., it need not cost more than ordinary milk. The only loss, then, incurred is the cost of upkeep of the depot. Moreover, as a week's supply or more can be purchased at a time the diffÉculty of fetching the milk daily does not exist, and one centrally placed depot can supply the whole of an ordinary provincial town. In Leicester when we supplied humanized milk on thegoutte de laitprinciple our depot cost nearly ~3oo a year, whereas now that we have practically abandoned the humanized milk and adopted dried milk the net cost will only be about a third of that sum. The fact that in the case of an infants' milk depot started de novo for dried milk only no capital outlay on machinery is necessary, makes the provision of an infants' milk depot in a small district a comparatively easy matter. Dried Milk v. Patent Foods.--One reason why dried milk is so popular with the mother is because it possesses all the convenience of the " p a t e n t " food made from cereals. Indeed, they like to refer to it as a "food," rather than as milk. Yet it is evident that the serious objection to the use of patent foods of the class referred to--viz., that they tend more or less to supplement milk in the infant dietary--does not apply to a " f o o d " which, after all, is milk. It is possible that dried milk may help largely to oust these proprietary foods, with great benefit to our infant population. It now remains to consider the objections to dried milk as a food for infants. The immed i a t e and palpable effects of substituting dried milk for fresh milk is in many cases, as has been said, distinctly beneficial. Is there any danger, however, that the ultimate effect of its prolonged use may be detrimental? At first, it must be confessed, the writer was rather apprehensive that the dangers supposed to lie in the use of sterilized milk would exist
PUBLIC HEALTH.
1910.
fortiori in dried milk, and t h a t a t e n d e n c y to the
m o r b i d condition often referred to as "scurvy- r i c k e t s " m i g h t sooner or later m a n i f e s t itself. Before going further, it m a y be observed t h a t the highest authorities now deprecate the t e r m " scurvy rickets," as really indicative of two distinct conditions, which, t h o u g h t h e y m a y co-exist, h a v e an entirely different etiology. S c u r v y is believed to be chiefly due to a lack of a n t i - s c o r b u t i c p r o p e r t i e s ( w h a t e v e r their n a t u r e m a y be) in the food ; whilst the essential factor in the c a u s a t i o n of rickets is n o w believed to be a deficiency of fat in the infant dietary. I f this view is correct, t h e r e is not m u c h need to fear t h a t t h e use of dried milk will produce rickets, providing t h e p r o p o r t i o n of fat is not diminished. As regards scurvy, however, the case is different, for it is reasonable to suppose t h a t the a n t i - s c o r b u t i c properties in dried milk will be affected. I t is a question, therefore, for experience to decide, and from the outset I have k e p t careful look-out for a n y u n t o w a r d s y m p t o m s . W e h a v e n o w used dried milk at the Leicester milk d e p o t for s o m e t h i n g like 4oo infants, a n d for periods r a n g i n g f r o m a few weeks up to ten or twelve m o n t h s . I n addition to seeing m o s t of t h e cases personally from t i m e to time, I have m a d e inquiries f r o m fifteen m e d i c a l m e n p r a c t i s i n g in the districts whence m o s t of the cases are drawn, and inquiries have also been m a d e f r o m the m o t h e r s s u b s e q u e n t to the infant h a v i n g been t a k e n off the d e p o t ; but in no i n s t a n c e have a n y cases been discovered in which t h e r e was reason to t h i n k t h a t t h e p r o l o n g e d use of dried milk had been detrimental. DISCUSSION. DR. BOSTOCK HILL prefaced his opening of the discussion by thanking Dr. Miltard for his excellent paper, which, he said, was one of great value, dealing as it did with a question of much interest to medical officers of health. H e had always urged the use of sterilized milk as a means of remedying the present defects of dealing with the mitk supply, and he was pleased to have the corroboration of Dr. Millard. H e was convinced, from constant observation, that there was no danger from the use of sterilized milk; but he did not think that the milk should be heated beyond lO4 deg., as the constant use of superheated milk would be prejudicial. One point to be urged for the use of dried milk was that it would satisfy the yearnings of the average mother to give the child some form of solid food.~ H e laid particular stress upon the fact that the use of dried milk would do away with the use of artificial foods, upon the worst types of which a great
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many hand-fed children were brought up. T h e r e are certain kinds of artificial foods in general use which are very prejudicial to the health of infants, he said, and if we can get the mothers to use dried milk in preference to these artificial foods it would be an advance in infant feeding. DR. t3ARWISE said that he could bear eloquent testimony to the investigations made by Dr. Millard. Dried milk certainly had another advantage which Dr. Millard had not mentioned, and that was that in India and Ceylon, where there is no milk to be had at certain periods of the year, dried milk would be invaluable. DR. ROBERTSON said that he had an open mind on the question of dried milk, but he still had a preference for fresh milk. T h e reason of his hesitation in advocating the use of dried milk was that there was a large amount of evidence in regard to the production of rickets as the result of feeding not only babies but adults on things that were not fresh, and he thought probably all of . them would agree that where we could get clean and good milk, we did not want dried milk. W e are, he said, very grateful to Dr. Miltard and medical officers of health in other towns for the testing they have done in regard to dried milk, which is very valuable. H e did not believe the giving of an imperfect food for a short time would do any baby harm, but he would ask Dr. Millard if dried milk had been used over long periods. There were one or two interesting points upon which he would like information. Dr. Millard said that tubercle bacilli were destroyed in dried milk; but he would like to know whether Dr. Millard had made this experiment himself. Dr. Millard said that the dried milk was more easily digested, and he believed that this was correct, but he did not know how it could be proved; some experiments were made which showed that in the laboratory it was more easily digested. Children who had sickness with ordinary milk would, he thought, have sickness with dried milk. Dm GARRE'rr said that this was a subject of particular interest from the fact that artificial feeding was so largely practised. It was very useful to have information concerning some new kind of milk food which could be relied upon. Personally, he thought that a great many of the arguments used against dried milk were wrong •and ill-founded ; artificial feeding coula be resorted to without success, but the fault mainly lay in the feeding being so badly done, and in the poorer classes the c~rnou~ of food was insufficient. In regard t o sterilized milk he believed that the scurvy which was met with at times was often due to insufficient feeding. A very great number of infants had been fed on sterilized milk and had done very well, and some had done very badly where there was a difficulty in getting a milk to suit them. No doubt, as Dr. Robertson said, if
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PUBLIC HEALTH.
we had/)use fresh milk this would be best. Milk :is a very great danger in regard to tuberculosis :and other infectious diseases, such as scarlet fever, etc.; and these dangers are obviated, he said, by the use of dried milk. D m MILLARD, replying on the discussion, said that he was extremely obliged for the criticism of his paper. It was quite true that some people did not find dried milk palatable, but some did, and certainly all. babies did. Babies, he said, showed a decided preference for dried milk over fresh milk, and he believed this was becanse the former was much more easily digested. Speaking on the question of cost, he said that he used castor sugar, as he did not think it necessary to use milk sugar, and he further stated that it cost very little more to feed a baby on dried milk than on dairy milk. T h e most serious criticism, he thought, was whether one could rely upon the complete elimination of tubercle bacilli; he had not personally made experiments to prove that this was the case, though such experiments had been made. If it were true that dried milk gained immunity from tubercle bacilli this would be a gre~t advantage, as it was impossible to safeguard all fresh milk, and would do away with infants getting the seeds of consumption from the cradle. Replying to Dr. Robertson, he said that in Leicester there were possibly fifty babies who had been fed on dried milk for over nine months, a n d perhaps 2oo for over six months ; about 19o babies were being fed at the preserit time. In some cases where dried milk had not given satisfaction, fresh milk had been tried successfully, but this had not happened in many cases. THE NEGLECTOF TUBEReULOSlS.--It may hot be
inappropriate to contrast the disproportionate fear of the public as regards scarlet fever, with its comparative lack of suffering and small deathrate, to their singular apathy and carelessness in reference to tuberculosis, a disease which is also infectious but frequently entails months or years of great suffering and expense, and has a mortality higher than all the zymotic diseases put together. If this disease were called a "fever" it might receive more attention from the legislature. It is also interesting to contrast the amount of money spent out of the public funds in this country for the purpose of limiting the spread of these diseases; in Margate the approximate annual expenditure of isolating and treating patients suffering from scarlet fever, diphtheria and enteric fever is ~3,ooo~ whereas the amount of public money spent on attempting to check the spread of tuberculosis came to only about ~7 during the year, and there are no public funds available for the treatment of the disease except at the workhouse.~Assuat Re:port of Dr. Bertra:n T~orstos,
Medical Ofice*, of ttea#h, Margate.
JuicE,
UNWHOLESOME PASTEURIZED SKIMMED MILK. By CHARLES PORTER, M.D., B.Sc., M.R.C.P. Ed., Barrister-at- Law, MedicaI Officer of Health, St. Marylebone.
A S the following case refers to a m e t h o d which m a y be adopted in dealing with impure milk under the sections as to u n s o u n d food in the Public H e a l t h Acts, it has been t ~ o u g h t w o r t h while to relate it. Some time ago the Public H e a l t h C o m m i t t e e of the Metropolitan B o r o u g h of St. Marylebone i n s t r u c t e d their medical officer of health to take samples of various foods and submit t h e m for bacteriological examination to Dr. E a s t e s at tile L a b o r a t o r i e s of P a t h o l o g y and Public Health. A considerable n u m b e r of the samples taken were of milk, and amongst these was one of pasteurized skimmed milk from an itinerant v e n d o r w h o s e " w a l k " lies mainly in those poorer parts of the district affected by Jewish and other aliens. The fluid is sold at 2d. or 2}d. per quart, and is dispensed from an o r d i n a r y I I - q u a r t h a n d , c a n , which is filled from time t o time from a large c h u r n on a handcart. T h e report received regarding this miik was dated D e c e m b e r I l t h , 19o 9, and was to the effect t h a t " t h i s sample contains a distinct trace of pus, a few red blood discs, and a large n u m b e r of streptococci, which are s o m e t i m e s p h a g o c y t e & T h e a m o u n t of e x t r a n e o u s matter (vegetable and mineral) is negligible. T h e streptococci have grown vigorously in culture, and also staphylococci and some bacilli. Spores of the B. Enteritidis sporogenes are present in every IO c.c. o f the milk. Remarks : T h e milk is quite unfit for h u m a n c o n s u m p t i o n by reason of its pus content, and a p a r t from this the pasteurization has been inefficient." I m m e d i a t e l y on receipt of this report a communication was sent to t h e m a n a g i n g d i r e c t o r of the pasteurizing c o m p a n y supplying the milk, directing his a t t e n t i o n to the findings of the bacteriologist, and advising him that greater care should be exercised in the future. Communications were also sent to the medical officer of h e a l t h of the district in which the premises of the firm are situated, and to the medical officer of health of the L o n d o n C o u n t y CounCil. At the same time consideration was given to the possibility of dealing with the milk under the sections in the Public H e a l t h Act relating to unsound food, and having the milk c o n d e m n e d and d e s t r o y e d after seizure in the usual wait. T h e only possible course seemed