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and supplied constantly stale and unfit for use, the ignorant farmers supposing that until sour it must be fit for use. The sooner pure, wholesome milk is taken for food after milking the better, and the delay of more than one hour, even under the best hygienic surroundings, is undesirable. Some complain that they cannot drink milk at all, or else must have it skimmed and stale. Of course this shows either an unnatural taste, or a diseased condition of the stomach, which should be remedied. The substances used for the adulteration of milk, not to speak of the impure water constantly used in them, increase the already numerous dangers existing in our milk supply. The importance of care in selecting an honest milkman (and there are such), but also a clean and intelligent one, cannot be overestimated. When in every town Boards of Health shall have been organized-real working boards and not complimentary ones-no one should be allowed to sell milk without a permit certifying that his cattle are healthy, properly fed, and that his premises are in a sanitary condition, i. e., that no contagious or infectious disease is prevalent, and the house used for the reception of milk in a safe sit iation as to air supply, and freedom from poisonous gases. This may seem a difficult reform to bring about, but educate the public to the necessity for reform, and the good results must sooner or later follow. The medical man in his mission among the sick poor is constantly reminded of the dishonesty of milkmen in general. The writer is almost a daily witness of the outrageous swindling of the poor by dishonest milkmen. Whose heart would not melt with pity to see little children whose only hope for life, perhaps, depended upon a supply of pure milk? How many times the struggle for life has ended because the last milk supply was adulterated or unfit for use! How many lives have been lost because the milkman could not or would not furnish wholesome milk! Go to the hovels of the poor and see the wan, thin faces so dependent upon milk cheated without mercy. I find upon investigation that the prices charged the poor for the miserable stuff called milk is exactly the same as that charged at the dwellings of the rich. A man's heart sympathizes with the poor and dying-the victims of this most cowardly of swindling. The gambler who robs his victim at the table is a prince beside the man who mercilessly cheats the helpless infant of the little nutriment it needs for life. This evil of swindling by milkmen and negligence in the handling of this precious nutriment deserves the most careful attention and consideration, and offences of this kind deserve the severest penalties.
Dr. Francis P. Kinnicutt, in a valuable article concerning "New Outlooks in the Prophyaxic and Treatment of Tuberculosis," in the New York Medical Record of May 21, 1892, states: Dr. Ernst, of
the Harvard Medical School, has demonstrated that "Experimental inoculation in rabbits and Guinea pigs and feeding experiments in calves and pigs, with both. the milk and cream of tuberculous cows, without disease of the udder, proved in the most positive manner that such milk is capable of producing tuberculosis in the consumer. Incidentally in experiments with milk taken at random from the common dairy supply of Boston, virulent bacilli were found in two instances. If Dr. Ernst's experiments are supplemented with the clinical fact of the frequency of intestinal and mesenteric tuberculous disease in children, and with the statement made in the form of a resolution, by the United States Veterinary Association, 1889, that from ten to fifteen per cent. of the dairy stock of the Eastern States is tuberculous, this subject assumes very grave importance. A bill of the inspection of dairies and the slaughter of tuberculous animals, I am happy to state will probably be introduced in the legislative houses, in the State of New York, during the present session. Such an example it is reasonable to hope would gradually be followed by the Legislatures of other States. In the meantime, in the absence of necessary legislation, the only safeguard possessed by the public against possible infection through dairy products consists in the sterilization of milk and cream by boiling, or through the use of steam sterilizers. Investigation conducted in the Imperial Health Bureau of Berlin demonstrate that tubercle bacilli also retain their vitality in butter and cheese frequently for weeks."
It is a very common custom for people visiting the city on business, who cannot afford time for regular meals, to drink a glass of milk, frequently purchased at corner groceries or restaurants. Many people, opposed to the use of intoxicating beverages, drink milk. We can readily understand how, if these facts become known concerning the dangers from impure milk, the use of intoxicants will be largely increased. The temperance question then should concern itself in the hygiene of our milk supply as one of great importance. It would seem an injustice that men who zealously avoid intoxicants, taking milk instead, should expose themselves to the serious danger of tuberculous infection.
ON THE STERILIZATION OF MILK AT
WITH DESCRIPTION OF A NEW AND SIMPLE APPARATUS APPLYING THE PRINCIPLE OF PASTEURIZATION.*
BY ROWLAND GODFREY FREEMAN, M. D., ASSISTANT PHYSICIAN TO ROOSEVELT HOSPITAL, OUT-PATIENT DEPARTMENT; PATHOLOGIST TO ST. MARY'S HOSPITAL, NEW YORK.
Since attention has been directed to the large number of bacteria in the ordinary milk supply, some at
*Read before the Section of General Medicine of the Academy of Medicine, New York, June 20, 1892.
least of which appear to be deleterious, efforts have been made to more or less completely kill them by means of heat sterilization. This has, until recently, been accomplished by exposing milk to a temperature of 100° C. (212 F.) for a period varying from twenty minutes to an hour and a quarter. After an experience of six years with milk so prepared, the general verdict of the profession is, I believe, that while sterilized milk is most valuable in the treatment of gastro-intestinal disorders, it is very often unsatisfactory when used as a regular food, seeming for some reason not to fulfil the condition of perfect nutrition. Analyses explain this, in a measure, by showing that various chemical changes take place in milk between 75o C. (167 F.) and 100° C. (2129 F.) and that these changes become more marked as the temperature becomes higher. According to Leeds,' sterilization at the boiling point of water or 100° C. (212° F.) causes the following modifications in the milk: The starch liquefying ferment is destroyed and coagulated. A portion of the lactalbumin is coagulated. Caseine is rendered less coagulable by rennet, and is acted on slowly and imperfectly by pepsine and pancreatin. Proteid matters attach themselves to fat-globules and probably bring about a less perfect assimilation of fat. Milk-sugar, by prolonged heating, is completely destroyed. According to Koplik, "from the temperature of 75° Celsius upward there is a separation of the serum albumin of the milk; the caseine loses its coagulability to rennet, and at 85° C. amounts of rennet, which for the raw condition of milk are found sufficient to act, cease to be effective." Heuppe, quoted by Koplik, considered that, from a physiological standpoint, milk is best sterilized, if possible, under a temperature of 75° C. In the meantime it has been shown by investigators that temperatures lower than 100° C. (212° F.), if continued for a short time will destroy a very large proportion of the germs, and will destroy with certainty many pathogenic germs which find their way into milk either from the cow or as external contaminations.
The problem then presents itself to devise a method of preparing milk which shall destroy by efficient means the contained germs, and yet in the least possible degree interfere with its nutritive qualities. In other words, the minimum temperature used must be high enough to destroy most of the germs; the maximum must be so low as will not alter materially the chemical composition of the milk. Pasteur found in 1868 that exposure of wine for a short time to 55° C. would prevent its spoiling; other observers have found that 60° C. (140° F.) to 70° C. (158° F.) was sufficient to kill bacteria. The term pasteurization is now used for any process by which the germs of wine or milk or other fluid are destroyed by the use of heat between 55 C. and 80° C. followed by rapid cooling.
It should be mentioned that pasteurization does not usually render all germ-containing fluids absolutely sterile, all spores are not deprived of life, and certain vegetative forms may prove invulnerable. But a sufficient number of such forms may be killed as to check, if not permanently hinder, fermentative changes. The rapid cooling is necessary to prevent the spores which remain in the fluid from developing.
Of the thoroughly known pathogenic germs which may exist in the milk, the bacillus tuberculosis, in the light of our present knowledge, is one of the most important. As the result of very elaborate and recent experiments by Yersin, Granchier and LidouxLibard, and Bitter, one may conclude that any of the following exposures to heat will destroy the bacillus tuberculosis in milk: 75° C. (167° F.) for ten minutes; 70° C. (158° F.) for fifteen minutes; 68° C. (154° F.) for thirty minutes.
It is practically difficult by microscopic examination, by inoculation experiments, or physical examination of cattle, to determine that the milk of any cow is free from tubercle bacilli. It seems important, therefore, that pasteurization should be carried out with a sufficient temperature to destroy with certainty the bacillus tuberculosis. Concerning other pathogenic bacteria, Van Geuns, found that a few seconds' exposure to 60° C. (140 F.) would kill the cholera sporilla, the Finkler Prior bacillus, the typhoid bacillus, and the pneumococcus of Friedlander.
While it is important to destroy the pathogenic germs above described, the beneficial effects of sterilized milk, especially in summer diarrhoea, are undoubtedly due to the destruction of other, as yet little known forms which the milk, especially in summer, is apt to harbor. Experiments already done in low temperature sterilization of milk and those to be detailed below, would lead us to the belief that these unknown deleterious germs may also be destroyed by this temperature.
From what has been stated one may conclude that a temperature of not less than 70° C. (158° F.) will render milk sufficiently germ-free for infant food, and that a temperature of less than 80° C. (176° F.) will not injure milk materially. Methods of pasteurizing milk in quantities have been presented to the public both in Germany and in this country, but as far as I know no such method for household use has been published. Such an apparatus should be a simple affair for use on a stove. The problem of sterilization at 100° C. (212° F.) was fairly simple, since the boilingpoint of water is a definite temperature, and boiling produces phenomena easily recognized by anyone. To devise an apparatus for a lower temperature seemed more difficult, because the use of a thermometer is to be avoided. It occurred to me that by immersing a certain definite amount of milk in a properly pro
portioned bulk of boiling water, the source of the heat having been removed, the temperature of the milk could be raised to about the desired point, i. e., 75° C. (167° F.). Of course the bulk of the boiling water required depends both on the bulk and the temperature of the milk to be heated. The amount of water in my apparatus is such that in raising the temperature of the milk through 60° C. (108° F.) it loses itself an equivalent of heat, so that when the milk reaches its maximum temperature the water surrounding it is of the same temperature. The apparatus which I present is constructed on this principle of the distribution of heat through two fluids of unequal temperature, and will raise the contained milk through about 60° C. of temperature (from 15° to 75° C.) and keep it at about its maximum temperature for half an hour, after which there is a loss of about one degree every fifteen minutes.
The apparatus consists of two parts, a pail for the water and a receptacle for the bottles of milk. The pail is a simple tin pail with a cover; there is a groove extending around the pail to indicate the level to which it is to be filled with water, and supports inside for the receptacle for the bottles of milk to rest on. The receptacle for the bottles of milk consists of a series of hollow zinc cylinders fastened together; this fits into the pail so that the top of the cylinders are almost level with the top of the pail. I have experimented with other forms of receptacle, including an ordinary tin pail, but find this form the best. Either of two such receptacles may be furnished with the pail, one which will take ten six-ounce bottles, or one for seven eight-ounce bottles.
The apparatus is used in the following way. The pail is filled to the level of the groove with water, covered, and put on the stove to boil, the receptacle for the bottles being left out. Now the bottles of milk are filled and stoppered with cotton, and dropped into their places in the cylinders. Sufficient water is now poured into each cylinder to surround the body of the bottle. This is very necessary for conduction of heat. When the water in the pail boils thoroughly it is taken from the stove and set on a mat or table or other non-conductor, the lid is removed and the receptacle containing the bottles of milk is set inside. The lid is now put on again and the whole is allowed to stand half an hour, after which the bottles of milk are put in a refrigerator. In case there is no refrigerator in the house, measurably the same purpose may be attained by replacing the hot water in the pail by cold water, or, better, ice and water. The water must be renewed at frequent intervals until the bottles of milk are of the same temperature as the water used. Water from the faucet at this season, June, is just 20° C. (68° F.), which is the temperature to which it
is desirable to cool the milk as rapidly as possible. When cooled, ice may be put in the water in the pail, the bottles being left in place, or the bottles may be taken out and put in a cool place.
Milk subjected to this process, and put immediately into a refrigerator and kept there shows usually no change for several days. A precipitation of caseine takes place in a week or ten days.
I have made careful observations of the temperature of the milk in this apparatus during the various stages of the process, by means of thermometers in the bottles which pass out through holes in the covThe temperatures I have recorded are the temperatures at the bottom of the bottles, since this part of the milk heats more slowly than the top. The middle bottle does not have exactly the same temperature as the side bottles, but the variation does not exceed two degrees. The accompanying chart shows best the rapidity of the rise of temperature and the constancy of the temperature during the last fifteen or twenty minutes of the half hour exposure. It also shows well that milk at a low temperature is elevated through a greater number of degrees than milk at a higher temperature. This is an important fact, and tends to eliminate any error from the uncertainty of the temperature of the milk when put in the apparatus. I have found that the temperature of milk in a refrigerator during warm weather varies from 10° C. to 19° C. (50° F. to 64° F.), but is usually between 13° C. and 16° C. (55° F. to 61° F.) Such milk would reach about 75° C. (167° F.) in this apparatus. Referring to the chart, we see that the temperature rises through 40° to 45° C. (72° to 79° F.) in the first five minutes, and that a temperature of 70° C. (158° F.) is reached in eight to ten minutes, depending on the temperature of the milk introduced. In leaving the milk in this apparatus half an hour we expose it to a temperature of over 70° C. (158° F.) for twenty minutes. The cooling in the refrigerator is slow. It requires two hours and twenty minutes to reach 20° C.
I have made a series of experiments at the Bacteriological Laboratory of the College of Physicians aud Surgeons to test the efficiency of this apparatus in the pasteurization of milk. Specimens of milk obtained at different times and from different sources have been examined to determine the number of bacteria contained in one cubic centimetre before and after pasteurization. This was accomplished by planting in gelatine plates. While the raw milk used contained from 8,000 to 230,000 and more bacteria to each cubic centimetre, the same milk after pasteurization usually contained none.
Summary.-1. Both clinical and chemical evidence lead us to believe that milk is injured for infant food by the formerly practised methods of sterilization by boiling or steaming, or even by any temperature above 80° (176° F.)
2. Pasteurization with a temperature between 70° C. and 80° C. (158° F. to 176° F.) destroys tubercle bacilli, and, according to Van Geuns, destroys also the typhoid bacillus, the cholera bacillus, and the pneumococcus of Friedlander, also most of the ordinary milk-germs, and does not injure milk.
3. Milk may be pasteurized by simply immersing it in a proper proportion of boiling water, the source of heat having been removed, and leaving it so immersed for half an hour.
4. In the apparatus here described the proper proportion between the boiling water and the milk has been calculated and tested, and by the use of the apparatus in practice ordinary milk in summer is found to have been rendered practically sterile, and keeps unchanged in a refrigerator for several days.Medical Record.
Medical Society Notes.
THE LOS ANGELOS COUNTY MEDICAL
MEETING, FEB. 5TH, 1892.
DISCUSSION ON RECTAL ALIMENTATION.
Dr. O. D. Fitzgerald said: Amongst the diseases, which, from their hurtful interference with the normal alimental functions, and which bring into requisition the physician's aptitude for improvising some form of suralimentation so to speak, may be mentioned all forms of gastric ailments: such as gastritis, ulcer, cancer, stenosis of one or both orifices of the stomach,
stenosis of the esophagus, stricture of the bowel from any cause preventing normal alvine flow along the "wonderful alimentary canal" (talked about so much in the text-books of our grandfathers in medicine), and in any perforating or other wounds of the lumen of these organs.
I have prepared this paper for this occasion hoping to invite a free discussion on rectal alimentation, inasmuch as it now is a well-recognized and practical means of sustaining life, in cases which suffer from any of the above causes and are thus unequal to the work which in a normal condition is easily, and I may say unconsciously performed.
The repeated failures which have generally been reported, it is fair to infer have been due to the methods employed, the material used, or to the condition of the rectum, at time the nourishment was injected. One essential point to be borne well in mind is that the rectum must be empty and thoroughly flushed with tepid water. For this to be done properly, the patient should be seated on a stool prepared for the purpose, leaning forward on side of bed, or with his head and shoulders resting on the back of a chair, and the person administering the irrigation should sit at his back; the receptacle for the outflow placed on a shelf just under the opening in the stool the patient sits on, so that the injection can be discharged from bowels without patient having to change his position. (The Hanks Douche Pan is an excellent device for the purpose.-Ed.) This flushing should be repeated two or three times each sitting, in order to thoroughly wash out the bowel that it may be prepared to properly receive and appropriate the nourishment. Then wait an hour after this flushing has been completed, so that the rectum may have time to become passive. Have the patient in the recumbent position with a pad or bed pan under his hips; direct him to resist straining and to exert his will and muscular powers to retain the nourishment.
Another important thing is to have a well-working, hard-rubber syringe; it must be rectal ended and of a capacity of not over three fluid ounces. The predigested material is to be introduced after being warmed to a temperature of 98-100. It should be very slowly injected with the syringe, which should be also warmed and oiled. One syringeful-2 to 3 ounces-is sufficient for each enema. Should this be rejected, wait a reasonable time and try again, using less material.
Should tenesmus prove uncontrollable, an opium suppository may do good introduced into the rectum three hours before the next enema. In some cases cold applied to the perineum controls the straining, but this method is open to the objection that the cold thus applied would interfere in some measure with the absorption of the nourishment. Pressure should
be made against the anus after the injection, which aids greatly in retaining the enema.
The most usual cause of failure in the use of this means of sustaining the patient, is that the injections are too large-often six or eight ounces of fluid, are too rapidly introduced, and are not of proper temperature. These enemata should be given every eight hours-three in the twenty-four hours. This seems to have been followed by the best results, and should be persevered in regularly to obtain the full benefit; and it is a matter of observation that the nervous system gets accustomed to these regular hours of feeding as it does to our ordinary meal times. It has been found that the most convenient times to administer these enemata are about 7 o'clock in the morning, 3 in the afternoon, and 11 at night. Upon examining the well-formed daily stools of patients thus fed, it will be surprising to observe the close analogy between this and digestion proper. The substances commonly used for this form of alimentation have been milk, eggs, concentrated beef extract, beef or chicken peptonoids, beef soup, chicken broth, whiskey. Disappointment, however, has usually followed this class of nutrients.
Prof. Brown-Séquard gives a good point, viz.: “In a therapeutical point of view the question at the present time is to know whether, on mixing with the alimentary matters-either gastric juice or pancreatic juice and injecting the mixture into the intestinal canal, digestion of these matters will take place with absorption of the products of digestion.
These experiments and clinical observations of Leube and Fiechter, and those of Brown-Séquard himself, place the fact quite beyond contradiction. And experiments showing that the large intestine is not possessed of digestive functions, do not contradict this assertion. It is a question of artificial digestion: in which the large intestine-rectum-may be as inert as any vessel in which this might be conducted." (American Journal of Medical Science, 1880, p. 256.)
I shall not claim originality in this paper, only upon the mode of preparing the injection; and which, in at least one case and that a so-called gastric cancer, I obtained the best results, so far as nourishing the patient was concerned. I kept him on the preparation per rectum for nearly two months, and at post-mortem the body was in a reasonably well-nourished condition; in fact, the patient had kept his flesh remarkably well for a subject of a malignant disease as cancer, involving as it did the stomach, pancreas, liver, and mesentery; a fact which I dare say Drs. Washer and Hughes, who saw this case with me in consultation-also Drs. Ainsworth and Crawford, who kindly gave their presence at the post-mortem, will corroborate. Following is mode, etc., of how I prepared and administered nourishment in these cases:
The quantity of meat required when patient has to be maintained solely by rectal feeding, is at least twelve ounces per diem-should be fresh and juicy and clear of fat--and of pancreas (fresh also) four ounces, and is prepared as follows: Bruise the pancreas in a mortar with a little tepid water--or liquid beef peptonoids, which is better--keeping the pancreas at a temperature of about 100° F. This is done by placing the mortar in a pan of water at the required temperature (temperature of water in the pan should be 104° F.). After triturating well, press the pulp on a cheese cloth to get rid of the pulp-fat, strings, etc. The liquid thus procured is now intimately mixed by triturating it and the beef, keeping the mixture at a temperature of about 100° F. If desired, the yolks of four eggs may now be added to it. This material is kept at a uniform temperature of 100° for two hours, when digestion is completed. Pass the emulsion-like material through a tolerably fine sieve to get rid of any remaining fibrous strings. If now it should be too thick to pass through the syringe, it may be rendered thinner by adding a sufficient quantity of liquid beef peptonoids. By placing on ice it can be kept several hours.
"By this procedure we have the advantage of injecting--not substances in a state of pulp, which have not been digested, and which may be rejected, but alimentary substances that have undergone, at the temperature of the body, the action of the dissolving ferments, unmixed with the debris of useless tissues; and therefore lending itself to rapid and easy absorption." (Medical Times and Gazette, November 29, 1879.). In closing this paper, may I express the hope that the profession will be induced to give this subject a careful examination and fair trial; believing as I do that great relief will be secured to a class of cases heretofore almost entirely abandoned to the ruthless pangs of hunger; and it may be some are allowed to starve to death, who, had nutrition been supplied, would have recovered.
The following theorem I submit for an index: 1. Diseases or conditions of system requiring rectal alimentation.
2. Conditions necessary to success.
3. Time and manner of emptying and flushing the bowel.
4. Times and mode of administering enema. 5. Kind of syringe necessary.
6. Amount of enema each feeding. 7. Frequency of enema.
8. Substance employed.
9. Mode of preparing same.
Dr. R. W. Miller employed it repeatedly. It is strange how slow the profession have been in accepting this method of nourishment. Not more than twelve years ago many able physicians pooh-poohed