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171 trol, and (3) national eradication. These three points are in the last three lines of the paper. We suggest that slaughter be confined at first to pilot eradication schemes, to limit the financial outlay. Although it is a time-honoured method of throwing sand into the eyes of the observer, the suggestion that eradication would bankrupt the Treasury and ruin the dairy industry deserves comment. It is possible that 50,000 animals in Britain are secreting organisms at present. If all these were slaughtered in one year (which is most unlikely-the process would be spread over many years) the possible compensation would amount to El-2 million; if there are twice as many infected animals-E2-4 million. One of us (A. McD.) has estimated that the total annual loss to animal husbandry due to brucellosis in Britain is E16 million. We do not think this estimate is far out; but, even if it is six times too great, eradication of brucel- losis by slaughter with compensation would be less expensive than persistence of the disease. There is nothing revolutionary in this finding-Denmark and other Scandinavian countries found it to be true. Indeed, this is a very good example of the fact that health equals wealth-prevention of disease saves money. We were aware of the provisional results (as yet unpublished) of the Ministry of Agriculture survey of infection in dairy herds, which do not change the situation, and could have been arrived at from our surveys in Oxfordshire, and other studies of Brucella abortus in milk in other areas carried out some years ago.3 The mode of infection in cattle is usually by ingestion; but other routes have been incriminated and the usual route for experimental infection is by the conjunctiva. We particularly emphasise that infections from milk must be not less than 75% of the total P.H.L.S. figures for 1960-61,4 for occupational categories show not more than 25% of cases in occupationally exposed people. Thus pasteuri- sation to render milk supplies safe is still important. The infrequency of cases in persons known to be drinking raw milk is perhaps more apparent than real. It is often a question of non-recognition of brucellosis, which is charac- terised by undulant fever in only about one-third of the cases; the others may have irregular or intermittent fevers, and also the clinical manifestation of each acquired infection may be delayed in time so that results of infection are not seen imme- diately. Longitudinal study of exposed people would be necessary, as with tuberculosis. Chronic arthritic sequelae may be significant in occupationally exposed groups and have never been systematically looked for in this country. The important thing, therefore, is not to introduce the organism into the human subject. It is unjustifiable to assume that nothing has happened if there are no immediately recognised clinical cases. We think it incorrect to say: " We see only 100-200 cases each year in England and Wales." The P.H.L.S. has a record of 101 cases with serologic diagnosis in 1961. How many cases are seen and recognised but not reported, or seen and not recognised, no-one knows. We do know, however, the infecting dose of brucella organisms by mouth.5-7 In the case of S.19 variant, the dose to produce clinical effects is appar- ently 5 x 109 cells or about 01 ml. of liquid culture. Olitzki, using Br. melitensis Rev 1, found that if more than 100 mil- lion of the strain were administered orally a rise in agglutinin titre occurred. It seems likely that the oral dose of Br. abortus required to infect the human subject would be in this region. Lastly, we refer you to the name " undulant fever ". To use this name is misleading and lends imprecision to a disease which badly needs more precision in diagnosis and measurement of incidence. Brucellosis describes the disease in man and animals, and avoids the equally mis- 1. McDiarmid, A. Vet. Rec. 1960, 72, 423. 2. Stableforth, A. W. Personal communication, 1960. 3. Stableforth, A. W. Vet. Rec. 1960, 72, 419. 4. Wilson, G. S. Personal communication, 1962. 5. Morales-Oteto, P. Studies of Brucella Infection in Puerto Rico. Uni- versity of Puerto Rico, 1948. 6. Oluzki, A. L. Boll. Ist. sieroter. Milan. 1960, 39, 412. 7. Revich, S. J., Walker, A. W., Pivnick, H. Canad. J. publ. Hlth, 1961, 52, 285. leading name " contagious abortion" in cattle. For undulant fever, Bang’s disease, abortus fever, contagious abortion, Malta fever-read brucellosis, by which name the disease is more likely to be recognised in its various clinical manifestations in man and animals. Even if we must be thirty years behind Scandinavia in beginning to eliminate brucellosis, there is no need for us to use a name which has long been discarded elsewhere and which perpetuates a misconception about the clinical picture; this change at any rate would cost no money. P. W. BOTHWELL A. MCDIARMID H. G. BARTRAM H. A. MACKENZIE-WINTLE A. R. H. WILLIAMSON. Department of Public Health, Bristol, 2. HOSPITALS AND POWER CUTS R. N. G. ATHERSTONE. SIR,-The recent power cut at Wanstead Hospital must draw attention to the precarious position of many hospitals under similar circumstances. The critical sections at risk include operating-theatres, recovery-rooms, resuscitation units, respiratory-failure units, blood-storage refrigerators, and lifts transporting unconscious patients after operations. Standby automatic lighting from batteries is almost universal in operating-theatres, but what of the chances of a patient undergoing operation when the surgeons, anaesthetists, and nurses are suddenly presented with considerably reduced illumination (emergency battery lighting is rarely as good as normal lighting) ? Of equal importance today is the synchronous loss of power. Suction pumps, often lifesavers in anaesthetic, maternity, and recovery rooms, fail. Similarly, all other essential equipment grinds to a halt. Postoperative patients can die of obstruction in immobilised and darkened lifts. A power cut, whatever the cause, during more compli- cated procedures, such as intracardiac repairs on bypass, has every chance of killing the patient, because so many of the vital equipments can only work on electricity. Some time ago at the London Chest Hospital, we were agreed that a standby diesel generator was essential to work all equipment in theatres, recovery rooms, and respiratory-failure unit. This generator has been opera- tional over the past year, and is, I submit, cheap insurance against avoidable loss of life, or a faulty operation. What then of all the other hospitals at risk ? VAGOTOMY FOR PYLORIC-CHANNEL ULCERS SIR,-If, as they say, Mr. Burge and his colleagues believe that pyloric ulcers occur in hyposecreting subjects, how can they justify the use of vagotomy, the only purpose of which, so far as I am aware, is to reduce acid secretion ? They also revive and support Dragstedt’s theory that gastric ulcers are all due to hypersecretion of hormonal origin " the final proof of which-demonstration of increased circulating gastrin-cannot yet be obtained ". Surely the first thing is to show the hypersecretion. In point of fact, except for combined gastric and duodenal ulcers which I have reported to be associated with hypersecretion,l gastric ulcers to the left of the angulus occur in hyposecretors.2 It seems that gastric ulcers are of more than one kind, differing in their clinical behaviour, their secretion patterns, and even their blood-group characteristics.3 At one time they were all treated by gastroenterostomy. Later Dragstedt vagotomised the lot. But both approaches had to be abandoned. 1. Lancet, 1955, i, 266. 2. ibid. 1962, ii, 583. 3. ibid. 1957, ii, 578.
Transcript of HOSPITALS AND POWER CUTS
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trol, and (3) national eradication. These three points are inthe last three lines of the paper. We suggest that slaughter beconfined at first to pilot eradication schemes, to limit thefinancial outlay.Although it is a time-honoured method of throwing sand
into the eyes of the observer, the suggestion that eradicationwould bankrupt the Treasury and ruin the dairy industrydeserves comment. It is possible that 50,000 animals in Britainare secreting organisms at present. If all these were slaughteredin one year (which is most unlikely-the process would bespread over many years) the possible compensation wouldamount to El-2 million; if there are twice as many infectedanimals-E2-4 million. One of us (A. McD.) has estimated thatthe total annual loss to animal husbandry due to brucellosis inBritain is E16 million. We do not think this estimate is farout; but, even if it is six times too great, eradication of brucel-losis by slaughter with compensation would be less expensivethan persistence of the disease. There is nothing revolutionaryin this finding-Denmark and other Scandinavian countriesfound it to be true. Indeed, this is a very good example ofthe fact that health equals wealth-prevention of disease savesmoney.We were aware of the provisional results (as yet unpublished)
of the Ministry of Agriculture survey of infection in dairyherds, which do not change the situation, and could have beenarrived at from our surveys in Oxfordshire, and other studiesof Brucella abortus in milk in other areas carried out someyears ago.3 The mode of infection in cattle is usually byingestion; but other routes have been incriminated and theusual route for experimental infection is by the conjunctiva.We particularly emphasise that infections from milk must
be not less than 75% of the total P.H.L.S. figures for
1960-61,4 for occupational categories show not more than25% of cases in occupationally exposed people. Thus pasteuri-sation to render milk supplies safe is still important.The infrequency of cases in persons known to be drinking
raw milk is perhaps more apparent than real. It is often a
question of non-recognition of brucellosis, which is charac-terised by undulant fever in only about one-third of the cases;the others may have irregular or intermittent fevers, and alsothe clinical manifestation of each acquired infection may bedelayed in time so that results of infection are not seen imme-diately. Longitudinal study of exposed people would benecessary, as with tuberculosis. Chronic arthritic sequelaemay be significant in occupationally exposed groups and havenever been systematically looked for in this country. The
important thing, therefore, is not to introduce the organism intothe human subject. It is unjustifiable to assume that nothinghas happened if there are no immediately recognised clinicalcases.
We think it incorrect to say: " We see only 100-200 caseseach year in England and Wales." The P.H.L.S. has a recordof 101 cases with serologic diagnosis in 1961. How manycases are seen and recognised but not reported, or seen andnot recognised, no-one knows. We do know, however, theinfecting dose of brucella organisms by mouth.5-7 In the caseof S.19 variant, the dose to produce clinical effects is appar-ently 5 x 109 cells or about 01 ml. of liquid culture. Olitzki,using Br. melitensis Rev 1, found that if more than 100 mil-lion of the strain were administered orally a rise in agglutinintitre occurred. It seems likely that the oral dose of Br. abortusrequired to infect the human subject would be in this region.
Lastly, we refer you to the name " undulant fever ".To use this name is misleading and lends imprecision toa disease which badly needs more precision in diagnosisand measurement of incidence. Brucellosis describes thedisease in man and animals, and avoids the equally mis-
1. McDiarmid, A. Vet. Rec. 1960, 72, 423.2. Stableforth, A. W. Personal communication, 1960.3. Stableforth, A. W. Vet. Rec. 1960, 72, 419.4. Wilson, G. S. Personal communication, 1962.5. Morales-Oteto, P. Studies of Brucella Infection in Puerto Rico. Uni-
versity of Puerto Rico, 1948.6. Oluzki, A. L. Boll. Ist. sieroter. Milan. 1960, 39, 412.7. Revich, S. J., Walker, A. W., Pivnick, H. Canad. J. publ. Hlth, 1961,
52, 285.
leading name " contagious abortion" in cattle. Forundulant fever, Bang’s disease, abortus fever, contagiousabortion, Malta fever-read brucellosis, by which namethe disease is more likely to be recognised in its variousclinical manifestations in man and animals. Even if wemust be thirty years behind Scandinavia in beginning toeliminate brucellosis, there is no need for us to use aname which has long been discarded elsewhere andwhich perpetuates a misconception about the clinicalpicture; this change at any rate would cost no money.
P. W. BOTHWELLA. MCDIARMIDH. G. BARTRAMH. A. MACKENZIE-WINTLEA. R. H. WILLIAMSON.Department of Public Health,
Bristol, 2.
HOSPITALS AND POWER CUTS
R. N. G. ATHERSTONE.
SIR,-The recent power cut at Wanstead Hospital mustdraw attention to the precarious position of many hospitalsunder similar circumstances. The critical sections at riskinclude operating-theatres, recovery-rooms, resuscitationunits, respiratory-failure units, blood-storage refrigerators,and lifts transporting unconscious patients after operations.Standby automatic lighting from batteries is almostuniversal in operating-theatres, but what of the chancesof a patient undergoing operation when the surgeons,anaesthetists, and nurses are suddenly presented withconsiderably reduced illumination (emergency batterylighting is rarely as good as normal lighting) ? Of equalimportance today is the synchronous loss of power.Suction pumps, often lifesavers in anaesthetic, maternity,and recovery rooms, fail. Similarly, all other essential
equipment grinds to a halt. Postoperative patients candie of obstruction in immobilised and darkened lifts.A power cut, whatever the cause, during more compli-
cated procedures, such as intracardiac repairs on bypass,has every chance of killing the patient, because so manyof the vital equipments can only work on electricity.Some time ago at the London Chest Hospital, we wereagreed that a standby diesel generator was essential towork all equipment in theatres, recovery rooms, and
respiratory-failure unit. This generator has been opera-tional over the past year, and is, I submit, cheap insuranceagainst avoidable loss of life, or a faulty operation. Whatthen of all the other hospitals at risk ?
VAGOTOMY FOR PYLORIC-CHANNEL ULCERS
SIR,-If, as they say, Mr. Burge and his colleaguesbelieve that pyloric ulcers occur in hyposecreting subjects,how can they justify the use of vagotomy, the only purposeof which, so far as I am aware, is to reduce acid secretion ?They also revive and support Dragstedt’s theory that gastric
ulcers are all due to hypersecretion of hormonal origin " thefinal proof of which-demonstration of increased circulatinggastrin-cannot yet be obtained ". Surely the first thing is toshow the hypersecretion. In point of fact, except for combinedgastric and duodenal ulcers which I have reported to beassociated with hypersecretion,l gastric ulcers to the left of theangulus occur in hyposecretors.2
It seems that gastric ulcers are of more than one kind,differing in their clinical behaviour, their secretion patterns,and even their blood-group characteristics.3 At one time theywere all treated by gastroenterostomy. Later Dragstedtvagotomised the lot. But both approaches had to be abandoned.
1. Lancet, 1955, i, 266.2. ibid. 1962, ii, 583.3. ibid. 1957, ii, 578.
