Hollinger Corp.
pH 8.5

Further Observations on the Milk
Supply of Washington, D.C.

G. LLOYD MAGRUDER, MD.
WASHINGTON, D. C.

ee aad

we

W”?

FURTHER OBSERVATIONS ON THE MILK
SUPPLY OF WASHINGTON, D. C.*

G. LLOYD MAGRUDER, M.D.
WASHINGTON, D. C.

At the meeting of the American Medical Association
held in June, 1907, I had the honor of taking part in
the symposium on milk, held in this Section. At that
time I submitted some observations on the origin and
progress of the movement for the betterment of the
milk supply at the national capital. Attention was
called to statements made in the “Report on Typhoid
Fever in the District of Columbia,” + submitted by the
medical society of the city to the House Committee on
the District in 1894, and to the report of the Washing-
ton Milk Conference. This report was issued subse-
quently, Aug. 20, 1907, by the Department of Agricul-
ture.”

Consideration of this subject is again desirable from
the facts that national, state and municipal authorities
have not yet fully realized the gravity of the situation ;
that many physicians still appear to be either ignorant
or indifferent to the dangers, and that only recently at
Washington, the National Association for the Study
and the Prevention of Tuberculosis, in a series of reso-
lutions regarding the pasteurization. of milk showed it-
self loath to admit positively conclusive evidence of the
communicability of bovine tuberculosis to man.

HISTORY OF EFFORTS FOR PURE MILK

Much interest was manifested in the presentations,
which I made and great satisfaction was expressed

* Read in the Section on,Preventive Medicine and Public Health
of the American Medical Association, at the Sixty-first Annual Ses-
sion, held at St. Louis, June, 1910. :

1. Report on Typhoid Fever in the District of Columbia, sub-
mitted by the Med. Soc. of the D. C. to the Committee on the
District of Columbia of the U. 8. House of Representatives, June
14, 1894.

2. Sanitary Milk Production. Cire. 114 Bur. Animal Industry.
Dept. Agric.

4

that the officials and the scientific experts of the
United States government had so actively joined in
this movement for the improvement of the public
health. I was so impressed with this reception of the
work of the Washington Milk Conference that immedi-
ately on my return to Washington I sought an interview
with Mr. Roosevelt, then President of the United States.
At this interview I submitted the following letter:

In view of the agitation that is now going on in Europe and
this country with reference to the question of the influence of
milk on infant mortality, as well as the causation of tuber-
culosis, typhoid and scarlet fevers, and diphtheria, I would re-
spectfully suggest that you direct the Bureau of Public Health
and Marine-Hospital Service to make a thorough investigation
of the milk industry in the District of Columbia from the farm
to the consumer. For this purpose the Bureau should be em-
powered to have the cooperation of other departments of the
government, and proper credit should be given for such aid.

Several foreign governments have recently ordered such
investigations, and the reports are frequently quoted by writ-
ers in the United States on these subjects. These writers have
expressed many divergent views.

The recent investigation conducted by the Bureau of Public
Health and Marine-Hospital Service mto the cause of the
prevalence of typhoid fever in the District of Columbia, which
report, including an examination of the milk-supply in the
City of Washington, has been printed and will be issued in a
few days, and the work of the Department of Agriculture con-
cerning the milk-supply at the farms, have shown that many
lives could have been saved and numerous cases of disease
avoided by more careful attention to the health of the dairy-
man, as well as of the cows, and the handling of the milk at
the farm, in transportation, and distribution in the city.

Much valuable information has been accumulated by both
departments, which can be consolidated and developed so as
to be utilized as a standard not only for the District of Co-
lumbia, but for the United States. This standard is very
essential at the present time, and, with the facilities at the
disposal of the United States government, should have equal
weight with that of any other government.

It can be readily shown that much can be done to improve
the milk-supply without materially adding to the cost of the
farmer and thus to the consumer.

The report of such an investigation should be freely illus-
trated that it may serve as an educational document.

President Roosevelt had previously shown great inter:
est in public health matters. He grasped the importance
of the subject and immediately directed an investigation,

5

which was conducted by recognized experts in the
United States Department of Agriculture, the United
States Public Health and Marine-Hospital Service of
the Treasury Department, and Dr. W. C. Woodward,
health officer of the District of Columbia.

These experts elaborated and endorsed in every par-
ticular the work of the Washington Milk Conference.
Their report under the title of “Milk and its Relation
to the Public Health,” was issued in January, 1908, by
the United States Treasury Department.* A _ revised
edition was issued January, 1910, as Bulletin 56. While
this publication is one of the most valuable ever issued
by the government on public health, its value would have
been greatly enhanced had it been submitted to a con-
ference of writers of the various articles and the advi-
sory board of the Bureau of Public Health and Marine-
Hospital Service. Then probably the statements would
have been in greater harmony and the endorsement of
such a distinguished body would have added greatly to
its authority.

The movement for the improvement of the milk-sup-
ply in Washington seems to have two distinct periods,
one from 1894 to 1907, the other from 1907 to date.
It will be desirable to recall some of the incidents con-
nected with this movement and the results that have
accrued. The progress of the first thirteen years was
great; that of the last three years has been marvellous.
The work done in Washington has exerted an influence
not only in this country but also in Europe. In fact,
its influence has also extended to Australia.

At a public meeting on Feb. 5, 1894, called for the
purpose of aiding in the improvement of the sanitary
condition of the city of Washington, the late Dr. Charles
Smart of the army read a paper on “The Causes and
Prevalence of Typhoid Fever.”

The statements made by Dr. Smart were so startling
and of such damaging character to the prosperity of the
city that I called the attention of the Medical Society
of the District of Columbia to them at the meeting held
on February 7 and moved for the appointment of a
committee to consider the subject. Dr. W. W. Johnston,
Dr. C. M. Hammett and myself were appointed as such
committee.

3. Bull. 41 Hyg. Lab. U. S. P. H. and M.-H. S:

6

It was found that the conditions were even worse than
Dr. Smart had represented. The committee considered
that there were four principal causes for the occurrence
of the disease: (a) Potomac water-supply ; (b) pollu-
tion of the soil by the leakage from privies, defective.
sewers and the backing up of sewage from tidal move-
ments; (c) to drinking of well or pump water; (d)
drinking of contaminated milk.

Among the recommendations of the committee, which
were unanimously adopted by the medical society, were
the construction of works for the filtration of the Poto-
mac or Washington water—the only method of purifica-
tion—the abandonment as rapidly as possible of all
wells within the city limits; the repairing of defective
sewers; the extension of the water supply and the sew-
ers; the making of house connections to these.

The views of the committee as to the unhealthfulness
of well waters were fortified by the results of bacteri-
ologic examinations of water from thirteen wells in the
city of Washington, made by Dr. J. J. Kinyoun. The
water from nine of these wells was classed as bad, and
from two as suspicious. It was recommended that the
nine wells be closed and that the remaining four be
kept under observation.

The influence of these two recommendations in the
committee’s report was immediately noticed:

9. Careful inspection of all dairies in the District from
which our milk-supply is drawn, and the enactment of a law
by which no milk shall be sold in the District without a permit
from the health office. The inspection should cover an exam-
ination at the dairies of all possible sources of infection,
including the water-supply.

10. The urging on the members of the profession of a careful
collation of all facts bearing on the mode of infection in each
case, and the advantage of reporting such facts to the society,
and the propagation of the doctrine that immediate disinfec-
tion of the stools is the first duty of the physician as guardian
of the health of the community.

It will be seen that pure milk and pure water, both in
the city and at the farm, and the avoidance of contact
with persons suffering with the disease, were the car-
dinal preventive measures recommended. The impor-
tance of these recommendations was immediately recog- ©
nized. The United States Congress, as well as the city
authorities, sought the aid of the medical society and
individual members in framing remedial legislation.

That the recommendations made in 1894 were im-
portant and proper is attested by remarks made at the
symposium on the causes of typhoid fever in the Dis-
trict of Columbia, held, on my motion, by the medical
society, Feb. 19 and 26, 1908. Dy. George M. Kober,
professor of hygiene, Georgetown University, said that
“every point developed in recent discussions, save the
influence of domestic filters and water-coolers, had re-
ceived consideration before.” Dr. Kober’s investigation
in 1895 confirmed in every particular the conclusion
reached by the committee of the medical society in
1894, and developed two new facts, viz., the percentage
of imported cases and the agency of flies in the trans-
mission of the disease. Dr. William C. Woodward,
health officer of the District of Columbia, said that the
problem “Why is typhoid fever more prevalent in the
District of Columbia than in other communities?” was
clearly the problem before the medical society in 1894,
when it inaugurated the campaign against the disease,
and the clear realization of the problem to be solved
contributed very largely, no doubt, to making the work
of that committee as thorough and the results as com-
plete as they were.” It may safely be said that. aside
from the one or two new facts brought to light by Dr.
Kober’s investigations, to which Dr. Kober has referred,
no material fact has been disclosed by any subsequent
investigation that was not anticipated in the report of
the medical society.

The contention for pure water, pure milk, and the
avoidance of contact, outlined in 1894, as preventive
measures against typhoid fever is further sustained in
Bull. 44 of the United States Public Health and Marine-
Hospital Service,* as follows:

Thus far our studies indicate that typhoid fever will cease
to be a problem in-any community having clean water, an un-
infected milk supply, and in which cases of the disease are
treated as dangerous and contagious. ‘

In drawing up the conclusions and recommendations of this
report we have had the benefit of consultation with the ad-
visory board of the hygienic laboratory, composed of eminent
scientists and sanitarians. This privilege is appreciated and
we desire to acknowledge the help we have received from the
members of the board collectively and individually.

The first step toward carrying out the recommenda-
tion of the committee of 1894 was the passage of an

See ee Sa ES Se ee
4. Bull, 44 Hyg. Lab. U. S. P. H. and M.-H. S., May, 1908, p. 2

8

act by Congress, approved March 2, 1895, which re-
quired the inspection of all dairy farms and a permit
from the health officer of the District of Columbia
before milk could be sold for consumption in the city
of Washington. This requirement applied not only to
the farms in the District of Columbia, but also to those
in the states supplying milk to Washington.

CARD REGISTRATION OF DAIRIES

About this time Dr. W. C. Woodward was appointed
health officer. He instituted the registration of the
results of the inspection of the farms and depots on
cards known as score-cards. Washington has the honor
of being the first city in the country, if not in the
world, to require inspection of the dairy farms as well as
the milk depots in the city.

The use of score-cards has proved to be very popular
as well as valuable. Many states and cities have adopted
them. The United States Department of Agriculture
reports that it has supplied them to about 300 cities
in thirty-nine states. and that they are being widely
used. ‘The province of Ontario, Canada, has also adopt-
ed inspectors and the score-card system of recording
such inspection. Previous to January, 1908, less than
50 cities had sought the cooperation of the Department
of Agriculture in instituting inspection. These figures,
however, do not represent the full extent of the use of
the score-card system as it has been formally adopted
by the state health authorities of fifteen states, and is
being introduced by them in the cities under their super-
vision.

This inspection has revealed many unfavorable con-
ditions both at the farm and at the city depot. In-
sanitary houses, milk houses and barns were common.
The attendants on the cattle were careless of their per-
sonal habits and frequently were suffering from disease,
sometimes of a contagious character. Cattle were fre-
quently found covered about their flanks, legs, udders,
and tails with manure and other dirt, which readily
dropped into the pails while milking was being done.
Cattle were many times found suffering from constitu-
tional diseases as well as local affections of the udder.
Flies swarmed about the premises. Frequently on the
surface of the milk in the pails floated dead and dying
flies. With the knowledge now available of the habits

4)

of the fly, this condition alone is a most dangerous
source of milk infection. Dr. L. O. Howard in a recent
publication by the Department of Agriculture suggests
that the common house fly be’ known as the “typhoid
fly.’ The presence of sediment in the milk containers
was a common occurrence. This is especially danger-
ous, since it has been shown that the ingredients are
pus cells, blood, epithelium, barn-yard manure, and
varied bacteria, including colon bacilli, and, as shown
by Schroeder and Cotton, very commonly the tubercle
bacillus.®

Few, if any, facilities were found for boiling the
water to cleanse the utensils used in the handling and
transportation of milk, the hands of the milkers, or
the udders of the cows. Polluted water readily con-
taminates milk. This contamination rapidly multiples
at a temperature above 50 F. The knowledge which is
rapidly being accumulated as to chronic carriers of the
typhoid bacillus, and the common custom which pre-
vails in rural communities of depositing human excreta
on the ground, frequently in close proximity to resi-
dences, barns, and water-supplies, demand that the
water-supply on dairy farms should be frequently ex-
amined and carefully guarded against contamination.
The location of the premises for the storage and the
handling of dairy products in the city depots was fre-
quently most objectionable and at times entirely unfit
for such purposes.

The following are some results of one year’s use of
the score-card system of inspection at Indianapolis:

Dairies scored, 717.

Barns improved, 381.

New barns built, 41.

Milk rooms built or repaired, 319.

Visits made by request to advise about constructing new
barns or repairing old ones, 137.

The report of the official in charge says:

While at first we met with serious opposition, producer and
dealer have become convinced that instead of persecution, the
work is for their betterment.

Numbers have thanked us for insisting that they improve
their conditions, stating that they do not see how they could
have produced milk under the conditions they did.

5. See Bull. 99 and Cire. 118, Bureau Animal Industry, Dept. of
Agric. ‘

10

The records of inspection as kept on score-cards show
the result of intelligent inspection of the dairy farms
supplying milk to Richmond from May, 1907, to May,
1908. The first inspection in May gave an average of
41.5 out of a possible 100; the inspection in April of
the following year, twelve months later, gave an average
of 72 for the same premises. This demonstrates a gain
of nearly 100 per cent. for the year. The improvement
was steady throughout this time.

In the annual report of the Richmond, Va., health
department for 1908 the dairy inspector in his report
to the chief health officer says: “The disposition among
our dairymen to improve their plants is wonderful, and
all speak highly of the work of the health department.”

Washington city also furnishes an excellent illustra-
tion of the effects of intelligent inspection. The inspec-
tors and the producer have learned to understand each —
other. Many of the farmers welcomed the criticisms
and proceeded to remedy these defects, as it was found
that much could be done at an insignificant outlay of
time and money. Much higher scores were given in
many cases on the second inspection. As a result of this
educational inspection much milk is delivered to the dis-
tributing depots with less than 2,000 bacteria to the
cubic centimeter.

At the meeting held Sept. 22. 1909, in Washington,
of the Milk Producers’ Association of Maryland, Vir-
ginia, and the District of Columbia, President Thomas
in his address reminded the members of the association
that the day was past when the milk inspector was
“looked on as an irreconcilable enemy.”

Such expressions show the spirit with which intelli-
gent inspection is met. This educational inspection
means much to both producer and customer. It con-
tributes not only to the health of the families of both,
but also to that of the dairy herd. It is a well-known
fact that typhoid fever prevails to an alarming extent
in rural communities. It has. been found that it is
two and a half times more prevalent in the counties of
Maryland than in the city of Baltimore. Tuberculosis
is also quite common in the country.

RESULTS OF INSPECTION

Inspection has worked well; it should be perfected
and extended. It should be assumed by state and mu-

11

nicipal authorities and not left to the enthusiasm of
public-spirited physicians and other citizens. Washing-
ton has apparently had most satisfactory results from
the requirements for inspection. Dr. W. C. Woodward,
health officer of the city of Washington, D. C.,° says:

The death-rate from diarrheal diseases among infants during
the five-year period 1880 to 1884 was 162 per 100,000. During
the next five-year period it was 168, and from 1890 to 1894 it
was 175. In 1895 the milk law was enacted. From 1895 to
1899 the death-rate fell to 135; from 1900 to 1904 it fell to
109, and in 1905 it was only 104, and in 1906, 1907, and 1908
only 97 per 100,000.

In 1909 it fell to 72. It is gratifying to see that 405
fewer babies died in 1909 than in 1894, the year before
the milk law was passed.

The diagram that accompanies Dr. Woodward’s ar-
ticle (Chart 1) shows the above facts graphically.

MILK AND WATER AS AGENCIES

The improvement in the death-rate from diarrheal
diseases, typhoid, malarial and typhomalarial fevers has
also been very marked in the period since the enact-
ment of legislation governing the milk supply, and es-
pecially so since the active movement for its improve-
ment started in 1907. The title “typhomalarial fever”
is no longer used in the classification of diseases. It is
a question if the many deaths attributed to malarial
fever should not be considered as typhoid. The data of
the one are similar to those of the other. Chart 2 well
illustrates these observations. The rate 33.2 from
typhoid fever in 1909 encourages the hope that Wash-
ington with continued improvement in its milk-supplv
will soon attain a muéh lower death-rate.

The rate in 1909 would have been lowered had the
hospitals had a more nearly normal death-rate. There
seems to be a connection between the death-rate and the
milk-supply of the hospitals. In 1909 there were 780
cases of the typhoid reported with 114 deaths; 70 of
these deaths occurred in hospitals. With the normal
death rate of 10 per cent. 36 lives should have been
saved.

With the limit of safety of “inspected” raw milk fixed
at 100,000 the following numbers of bacteria per c.c.

6; Bulle 40 ys) Lab: U- S.4P:) B..and -M.-H. ‘Ss.

‘ 12

were found in milk furnished to Washington hospitals:
2,000,000; 2,800,000; 3,500,000: 4,000,000; 5,000,000 :
10,000,000; 10,000,000; 15,000,000; 50,000,000; 111,-
000,000.* ae<

The mortality from typhoid in some Washington hos-
pitals reached the appalling rates of 25, 20, 18 and 16
per cent., although a few have the normal death-rate of
10 per cent. But in only one instance was the German

& 880 70 1884
&

230

OLATH FRATE PEF? 100,000

BUDARREUBOR MERGE
a ie
RORESERERREAMAN

G0
Fold Nf AEST TESTE SSS SST ESTE iT sa

Chart 1.—Diagram showing decreasing death-rate of children
under two years of age from diarrheal diseases in the District of
Columbia following the enactment of the milk law of 1895. Dotted
lines show averages. (In 1909 the death-rate fell to 72.)

mortality rate of 5 per cent. approached, and this was
as low as 7 per cent.

It will be noticed that the highest record was reached
in 1890. Two factors can be considered as causing
this. Kober has attributed it to unusual contamination
of the Potomac water supply by the sewage from Cum-
berland, Md., where an epidemic of typhoid fever pre-
vailed in the winter of 1889-1890. I attribute it to the

7. See Bull. 41 Hyg. Lab. U. S. P. WH. and M.-H. S:. p. 481, et seq:

OUNIARHERL OSEASF S

| \7¥eHOID reve f
\ f

| \

DEATH RATE PEF 100,000.
&
Sq

& |
So
eo +6

& | WALABUL FEVER.

18.0 we H e

| 6.9 v Lead et
aes

a,

156 ‘aa

\ TYPHO-MALAAIAL. FEVER

~

.
‘eo -s—o- 2 - 2 0-2-2

Chart 2.—Diagram illustrating death-rate per 100,000 of popula-
tion for diarrheal diseases, typhoid fever, malarial fever and
typho-malarial fever, during the period 1890 to 1909 inclusive.

14

greater contamination of the milk-supply. This was
brought about by the abnormally high temperature that
prevailed during the winter. The Weather Bureau re-
ports it as having been the warmest winter for fifty
years. No ice was gathered. Consequently milk was
almost constantly exposed to a temperature conducive
to the growth of bacteria. It is well known that colon
and typhoid bacilli proliferate rapidly as soon as the
temperature goes above 50 F. May this not help to
explain the increased prevalence of typhoid in winter in
localities where the temperature goes repeatedly above
50 F.?

Chart 3.—Diagram prepared by Dr. Theobald Smith, showing
comparative number of bacteria found in 1 ¢.c. of Potomac water in
1886, and also death-rate of typhoid fever during same year.

The winter of 1889-1890, as stated, was the warmest
for fifty years. The winter of 1908-1909 was unusually
warm. The winter 1909-1910 was quite cold. From
January to May, inclusive, in 1909 (warm winter)
there were 236 cases of typhoid reported, while during
the same period of 1910 (cold winter) there were only
126 cases reported.

Comparison of the diagram with the one prepared
by Dr. Theobald Smith (Chart 3) on the seasonal
prevalence of typhoid fever practically eliminates the
Potomac water as a serious causative agent. The filtra-
tion plant now positively eliminates it, as is shown by
the accompanying table. There is no need to resort to
the boiling of Potomac water.

15

Contrary to every expectation, there was no diminu-
tion in the prevalence of typhoid fever following the
completion of the filtration plant in the fall of 1905
as compared with the few preceding years. Numerous
investigations were undertaken and reports made; some
covered conditions in the city, and others coy ered both
the city and the dairy farms.

RESULTS OF TEST FOR BACILLUS COLI OF 10 AND 1 C.C.

SAMPLES FROM FILTERED WATER, RESERVOIR AND
TAP WATER FROM VARIOUS PARTS OF THE CITY

Number Samples in which

Fiscal year. samples B. coli was posi-

examined. tively determined.

. Number. Percentage.
NOE Keyes son) oh <ihes(auce=/s7 502 8 1.60
UU Gaia stare 8 oo oo oo alee 1.630 a2 Soe
INF ets toa coin Loma ea rea 2232 42 1.88
MED Sco sears c beet os, 2,294 Hey 0.67
IN RD AN Ee cre icS Sf vel! oie .8 a 0 940 0 0.60

* Five months only, July to November, 1909, inclusive.

The Bureau of Public Health and Marine-Hospital
Service issued three special bulletins on “The Origin
and Prevalence of Thyphoid Fever in the District of
Columbia.” § From the peculiar limitations of-the func-
tions of this bureau the investigations were mainly of
the conditions existing in the District—not in the out-
lying states.

Continued study convinced me that stricter attention
must be paid to the conditions at the dairy farms, in-
cluding their water-supply, to which I had called atten-
tion in 1894. I submitted these views to the Hon.
James Wilson, Secretary of Agriculture, at an inter-
view in September, 1906.

Under the direction of the Secretary of Agriculture,
every one of the approximately 1,000 farms “supplying
milk to Washington was inspected by the Bureau of
Animal Industry i in the fall and winter of 1906-7. The
average score of these farms was as low as 45.03 out of
a possible 100. On 60 farms, taken at random, bac-
teriologic investigations of the springs and wells were
made by the Bureau of Plant Industry. These were
the first on record of an extended series of investigations
of their kind. Dr. Kinyoun did make six such examina-
tions in 1895, in four of which he found the water-
supply to be contaminated. Previously the analysis of
waters was only chemical. The revelations were start-

8. Bulls:35, 44 and 52, Hyg. Lab. P. H. and M.-H. S.

16

ling. ‘These showed that nearly one-half of the water-
supplies were contaminated with fecal bacteria and that
25 per cent. of the remainder contained many more
than 500 bacteria per cubic centimeter. The revela-
tions of contamination are quite astounding in other
states as they have been in the vicinity of Washington.
Examinations have been made in the District of Colum-
bia, Maryland, Virginia, Massachusetts, Illinois, Wis-
consin and Minnesota. The latest report,? by Keller-
man and Whitaker, issued Nov. 6, 1909, shows that out
of 79 samples of water from as many farms in Minne-
sota 59 were polluted, and on 23 of these farms there
was a record of typhoid fever. These studies have con-
firmed the contention of the danger from this and
other contaminations of milk.

CONFERENCE ON MILK-SUPPLY

The investigations of the dairy farms and city depots
supplying milk to Washington disclosed many alarming
conditions. ‘These were considered by the Medical So-
ciety of the District of Columbia and a number of inter-
ested citizens. I submitted the ascertained facts to
Mr. Macfarland, then president of the Board of District
Commissioners. Simultaneously Mr. Macfarland’s at-
tention was called to a suggestion made by Mr. EK. Ber-
liner that a conference be held on the milk-suppiy.
This suggestion was made at a meeting held at Mr.
Berliner’s house, when there was a discussion of Om:
Schroeder’s and Mr. Cotton’s recent publication on the
contamination of milk with tubercle bacilli and the sig-
nificance of such contamination. Mr. Macfarland at
once invited a number of gentlemen from private and
official life to take part in such a conference.

It was shown that milk and dairy products were dis-
seminators of disease. Repeated instances were cited of
outbreaks of typhoid fever, scarlet fever, diphtheria
and sore throat, as positively being traced to infected
milk. The fearful death-rate among infants, directly
from impure milk, was shown. Attention was also
called to the danger of milk as a carrier of tuberculosis.
Fortunately while pointing out these alarming condi-
tions, the conference pointed out the methods for modi-
fying the danger. The proceedings of the conference
were published by the Department of Agriculture as

9. Bull. 154, Bureau Plant Industry, Dept. of Agric.

a"

Circular 114 Bureau of Animal Industry under the title
“Sanitary Milk Production.” The value of the report
was greatly enhanced by the fact that it was issued after
careful consideration in conference by all of the contrib-
utors. It demonstrated the importance of occasionally
having the cooperation of official and non-official per-
sons. This furnishes another instance of the watchful-
ness of the Department of Agriculture over the public
health.

The London Lancet,'® in an editorial headed “Federal
Text-Book on Pure Milk Questions,” says of this cir-
cular:

The Agricultural Department at Washington has issued a
volume of reports containing the results of the conference of
experts called together by the department to consider the
various questions now agitating the country in regard to the
purity of the milk-supply. The conference consisted of thirty-
five recognized experts in the study of the questions involved.
This volume will be the recognized text-book of the health
authorities of this country for the present, as it carries the
weight of authority of these experts, and the endorsement of
the Department of Agriculture. In brief, these experts agreed
upon a definite milk program and have recommended that
public safety should be assured by legislation establishing three
classes or grades of milk—namely, certified, inspected and
pasteurized.

Constant instances of serious outbreaks of diseases
from contaminated milk are being reported.

The occurrence of 600 cases of streptococcus sore
throat in Stockholm, traced to a streptococcus abscess in
the udder of a cow with other reports of similar infec-
tions has drawn attention to the necessity of immediate
study of the significance of streptococci in market milk.

The rapidly accumulating reports of outbreaks of
typhoid fever resulting from milk infected by bacillus
carriers have excited an increased interest throughout
the world in the improvement of the milk supply. Dr.
Biggs, like many others, has been so impressed with the
danger from this source that he considers it almost im-
possible to secure a safe milk-supply without careful
and repeated inspection, including complete and_ re-
peated bacteriological examinations of every one con-
nected with the production and handling of milk. Asa
result of his report, covering this and other points, the

10; Lancet, London, 1907, ii; No, 13.

18

New York City Board of Health has adopted an order
requiring satisfactory pasteurization of milk used for
drinking purposes.

In the fall of 1908 over fifty cases of typhoid fever
in Washington, D. C., were traced to the supply of milk
from a single farm. The owner was a bacillus-carrier.
The supply of milk from this farm was stopped.

From the well-known prevalence of rural typhoid. the
presence of bacillus-carriers, and the existence of con-
taminated water-supplies at many farms which can
readily contaminate milk, it seems that milk is a far
ereater factor in keeping up the typhoid rate in Wash-
ington than a number of writers have been willing to
admit. I have always contended that dairy products
were the principal sources of the disease. In view of
recent investigations, I reassert my position.

BOVINE TUBERCULOSIS

During the past three years extraordinary progress
has been made in the study of the relation between hu-
man and bovine tuberculosis. The position of Koch
that bovine tuberculosis is a negligible factor in the
causation of human tuberculosis is no longer tenable.

The work of Schroeder and Cotton on this subject
attracted universal attention. It was deemed to be of
the greatest importance. The British Royal Commission
to inquire into the relation of human and animal tuber-
culosis, confirmed these experiments in every particular,
and so reported to the British Parliament in January,
1909, in its “Third Interim Report.” Their report was
based on the information obtained from these repeated
experiments.

Influenced by this report the Board of Agriculture
and Fisheries of Great Britain issued in May, 1909,
“The Tuberculosis Order of 1909.” This order provided
that after Jan. 1, 1910, milk sold in Great Britain
should come from tuberculin-tested cows, or should be
sterilized. These two paragraphs from this order are
very. positive :

As your local authority are doubtless aware, the subject of
tuberculosis in man and in animals, and the relations between
the disease in human beings and in animals has been under
careful investigation during recent years in this country and
abroad, and various phases of the question have been inquired
into by successive royal commissions. So far as regards the
possibility of the transmission of the disease from affected

19

bovine animals to man, the board are satisfied that it must
now be accepted as a fact that tuberculosis is transmissible
by the agency of milk used for human consumption. The
Local Government Board coneur in this view, and a bill was
introduced in the House of Commons by the President of the
Local Government Board on the 25th inst. designed, inter alia,
to afford protection to the public health from the risk of the
spread of tuberculosis by the means of milk used for human
consumption.

In considering the question in relation to animals, the fact
that the disease is communicable to man by milk has a ma-
terial bearing on the measures to be adopted. Any action
which results in the reduction in the number of tuberculous
‘bovine animals in the country must reduce the risk of the
spread of tuberculosis amongst the community, and if it were
possible to eradicate from this country the disease in animals,
a material step forward would have been taken in the cam-
paign against the disease in man.

The accumulated testimony on the communicability
of bovine tuberculosis to man was greatly accentuated
in a paper by Dr. W. H. Park, director of the research
laboratories of the Health Department of New York,
which he submitted in Washington, May 3, at the meet-
ing of the National Association for the Study and Pre-
vention of Tuberculosis.

In this paper he showed that 22 out of 84 cases of
tuberculosis of children under five years of age showed
the bovine type of tubercle bacili. Dr. W. H. Welch
noted that the cases reported by Dr. Park were not
selected cases.

PASTEURIZATION AND STERILIZATION

Even though the danger of contracting tuberculosis
due to bovine tubercle bacilli from dairy products can
be eliminated, if we can obtain milk from healthy cows,
there still remains the danger of contracting tubercu-
losis, due to human tubercle bacilli and other diseases
from contaminated milk. Milk can be made safe, how-
ever, by the proper application of heat. There are two
terms applied to tlre results of heating milk, pasteuriza-
tion and sterilization. These two terms must not be
confounded ; the former is a process that requires the
application of a much lower degree of heat than is
effective for the latter. Sterilization means the killing
of all the germs that may be present in milk. Pasteuri-
zation means the destruction of the disease germs that
are of more common occurrence in it, such as those of

20

tuberculosis, typhoid fever, diphtheria, ete. The investi-
gation of General Sternberg, confirmed by Dr. M. J.
tosenau, especially, have shown that the common or
pathogenic bacteria are unable to retain their life and
virulence when they are exposed to a temperature of
60 C. or 140 F. for a period of twenty minutes, and
that the value of milk as an article of food is not per-
ceptibly affected by the designated temperature. Pro-
fessor Kastle, of the University of Virginia, after ex-
tensive investigation, concluded that the designated tem-
perature, maintained for a sufficient time to destroy the
disease germs of common occurrence in milk, has no
deleterious effect on its nutritive value. Thousands of
children under the eyes of careful and competent ob-
servers have been reared successfully on milk so treated
without the slightest signs of scurvy or rickets. Row-
land G. Freeman has ‘recently shown that such out-
breaks haye been traced to mixed feeding; that milk
was an insignificant factor. His observations were
strengthened by those of numerous observers in Europe.
There boiled or sterilized milk was almost exclusively
used. The temperature required for sterilization does
destroy the enzymes and impair the nutritive value of
milk. This emphasizes the necessity for a proper appre-
ciation of the processes of pasteurization and steriliza-
tion.

It must be kept in mind that the advocates of pas-
teurization do not countenance the use of unclean or old
milk; on the contrary, they insist that pasteurization
should be apphed, but simply as a measure of safety
against the dangers from milk which no other precau-
tions can obviate. Furthermore, pasteurization should
be practiced under proper supervision, and that form of
so-called pasteurization which is to some extent com-
mercially practiced, during which milk is heated to an
unnecessarily high temperature for barely a fraction of
a mimute, should be emphatically discountenanced.
Health officers should be provided with properly equip-
ped laboratories to keep constant check on the output
of pasteurizing plants. Progressive men engaged in the
distribution of milk, cream, and ice-cream employ
skilled bacteriologists.: There are two noted instances
in Washington where this precaution has been taken.
The rarity of typhoid fever amongst the customers using
this pasteurized milk and ice-cream has been marked.

21

All milk, whether pasteurized or not, should be con-
sumed as soon as possible after milking.

It frequently happens that properly pasteurized milk
cannot be secured on the market. The observance of
the following directions for the home pasteurization of
milk, by L. A. Rogers of the Bureau of Animal In-
dustry, can then be practiced :

Milk is most conveniently pasteurized in the bottles in
which it is delivered. To do this use a small pail with a per-
forated false bottom. An inverted pie-tin with a few holes
punched in it will answer the purpose. This will raise the
bottles from the bottom of the pail, thus allowing a free cir-
culation of water and preventing bumping of the _ bottles.
Punch a hole through the cap of one of the bottles and insert
a thermometer. The ordinary floating type of thermometer
is likely to be inaccurate, and if possible a good thermometer
with the scale etched on the glass should be used. Set the
bottles of milk in the pail and fill the pail with water nearly
to the level of the milk. Put the pail on the stove or over a
gas flame and heat it until the thermometer in the milk shows
not less than 150 nor more than 155 F. The bottles should
then be removed from the water and allowed to stand from
twenty to thirty minutes. ‘The temperature will fall slowly,
-but may be held more uniformly by covering the bottles with a
towel. The punctured cap should be replaced with a new one,
or the bottle should be covered with an inverted cup.

After the milk has been held as directed it should be cooled
as quickly and as much as possible by setting in water. To
avoid danger of breaking the bottle by too sudden change of
temperature, this water should be warm at first. Replace the
warm water slowly with cold water. After cooling, milk
should in all cases be held at the lowest available temperature.

This method may be employed to retard the souring of milk
or cream for ordinary uses. It should be remembered, however,
that pasteurization does not destroy all bacteria in milk, and
after pasteurization it should be kept cold and used as soon as
possible. Cream does not rise as rapidly or separate as com-
pletely in pasteurized milk as in raw milk."

CONCLUSION

If the lessons taught by these observations be heeded,
a great step will be made toward the control of milk-
borne infections. Dollars spent by the thousand for
prevention will save millions needed for the care of
those afflicted with disease, to say nothing of the days
of suffering that will be avoided.

11. Cire. 152, Bureau Animal Industry, Dept. of Agric.

22

It can no longer be doubted that dairy products—and
this term includes milk, cream, ice-cream, butter and
cheese—are excellent vehicles for the dissemination of
pathogenic bacteria. Outbreaks of typhoid fever, scar-
let fever, diphtheria, sore throat, and intestinal disorders
of children have been definitely traced to contaminated
milk. The proofs of the danger of tuberculous infec-
tion from these products are accumulating daily. ‘I'he
opportunities for such infection are manifold. With
the greatest vigilance on the part of trained inspectors
and the greatest care on the part of the householder this
infection cannot be entirely prevented. The house-
holder also has a duty to perform to protect milk from
contamination after it has been delivered.

Of course the carrying out of the recommendations
for the production and delivery of more sanitary milk
entails additional expense at the farm and the city
depot. But the receipt of a single additional cent for
a quart of milk would justify many improvements by
the producer and the seller. A single case of sickness
or a funeral resulting from contaminated milk would
cost far more than the shght additional price of better
milk for a long period.

Under these circumstances there should be no ques-
tion about demanding that milk should be produced
under conditions that would entitle it to be entered
under Class 1 (certified milk) or Class 2 (inspected
milk) as prescribed by the Washington Milk Confer-
ence; or, in case it does not conform to the requirements
for these classes, that it should be efficiently pasteurized
(Class 3). This classification, prepared by Dr. A. D.
Melvin, Chief of the Bureau of Animal Industry, and
approved by the Washington Milk Conference, is
more fully described in Circular 114 of the Bureau of
Animal Industry already referred to. It is a classifica-
tion that will give us, not bad, indifferent and good
milk, but good, better and best milk. To produce milk
under any of these classes rigid inspection is required.

The prices that must be charged for the first class
make it almost impossible for the man of moderate means
to avail himself of such milk. Class 2 can be produced
at a lower price, but would still cost more than ordinary
milk. Hence the masses must resort to the milk of Gina
3. With the precautions suggested, they would reason-
ably be assured in the use of this milk of a safe and

23

wholesome supply at but a trifling advance in the price.

Those who are interested in the improvement of the
milk supply and who wish to obtain a comprehensive
summary of facts bearing thereon, are advised to write
to the Secretary of Agriculture at Washington, D. C.,
for a copy of Circular 153 Bureau of Animal Industry,
issued April 28, 1910. The title of the circular is “The
Dissemination of Disease by Dairy Products and Method
of Prevention.”

Stoneleigh Court.

ABSTRACT OF DISCUSSION

Dr. Witu1AM C. Woopwarp, Washington, D. C.: After search-
ing for a proper basis on which to determine whether or not
we have achieved any substantial results through our milk
inspection service, I selected deaths from diarrheal diseases
only, among children under 2 years of age, and it is to those
alone that the chart exhibited by Dr. Magruder relates. It is
true, as Dr. Magruder says, that the method of milk inspection
in use in the District of Columbia was original with a com-
mittee of the medical society of the district, on which com-
mittee I had the honor to serve. Working quite independently —
of anything that had been done previously, so far as we then
knew, we devised it. Later, however, it came to my attention
that as far back as 1873, the three food inspectors who were
then doing duty in the District of Columbia had united in a
formal report to the then board of health recommending this
very method of inspection. This proposed method included
not merely the inspection of the farms by the inspectors in the
service of the then existing board of health, but included also
the permit system, whereby one city or one state can control
the situation outside of its territorial jurisdiction. Later,
about 1884, one of my predecessors actually inspected some of
the dairy farms supplying milk to the district. I mention
these things so that honor may go where honor is due. Had
these early workers had back of them such public sentiment
as was created by the publication of the admirable report of
Dr. Magruder’s committee, that first pointed out the probable
sources of typhoid fever in the District of Columbia, their
work would doubtless have continued. As it was it died ut-
terly, even its memory having passed from the public mind.

Dr. WiLttIAM H. Wetcu, Baltimore: I think that a model
demonstration exhibited in the national capital is significant
and impressive, and likely to be productive of results to the
rest of the country. Of course,-we all realize, I think, that
sanitary problems connected with milk are about the most
urgent and perplexing, in many ways, of solution, of any.
Some years ago in Baltimore we had made an endeavor, at

24

least, to start the same sort of a campaign of education of
the public regarding milk that we had attempted in regard to
tuberculosis. It may not be known to all that the first tuber-
culosis exhibit was that arranged by Dr. Fulton in Baltimore.
It was a great success there, far beyond any thing we dreamed
of; and since then it was adopted elsewhere; but give him
credit for that. We have attempted to do the same thing for
milk, but it has not had the same response; but I think it is
a good idea, and that possibly the time is now more suitable.

It may be that the large mortality in the hospitals is due
to the poor quality of the milk used there; but there is a
question whether the high mortality of those particular hos-
pitals is due to the milk.

Dr. B. FRANKLIN Royer, Harrisburg, Pa.: Members of this
Section might be interested in the educational campaign un-
dertaken by the Department of Health in Pennsylvania. Three
years ago our health officers, the men who institute quaran-
tine for us, placard and disinfect premises, ete., were trained
for dairy inspection by placing suitable literature in their
hands and by having them further instructed by the county
medical inspector under whom they work.

At the present time all dairy farms in the commonwealth
are inspected twice each year. In our winter inspection com-
pleted some time in March we reached a total of 55,000 farms
and stables producing milk for sale to creameries, condenseries,
cheese factories, wholesalers, retailers and for sale from indi-
vidual dairies. The inspection up to the present time has
not, of course, been done with the great detail practiced at
Washington, and it in no way interferes with towns and cities
that have already some system of inspection of their own. In
fact, it is a campaign intended to reach the men who are
handling the cows and stables and caring for the milk in the
country. After the inspection is made circulars are handed
these men describing conditions that should exist, emphasizing
particularly the need for cleanliness of cows’ flanks and udders,
the need for excluding all forms of dirt from the milk and
the importance of cooling it at once.

We are now sending letters to each producer calling atten-
tion to the insanitary conditions found. This work reaches
far back into the country district where the initial infection
of milk commonly begins,

We have a statute which makes communicable diseases re-
portable, typhoid included. On receipt of such report telling
us of the existence of typhoid, diphtheria or scarlet fever on
a premises from which milk is sold, our county medical in-
spector at once visits the premises and establishes the depart-
ment’s regulations for the control of the milk-supply. If such
regulations cannot be established, the sale of milk is stopped
or the stock is transferred to a neighboring farm.

Dr. WILLIAM EpwWARD GRANT, Louisville, Ky.: As has been
suggested, we look up to Washington; what governmental au-

20

thorities order and advise has great influence throughout
the entire country. I am acting as health officer for my city,
and we are much interested in what Washington tells us.
Through such influence, in part, we have been able to get
every cow that produces milk for the city I live in tuberculin-
tested. We had a hard fight to accomplish this and it took
six to eight months of very earnest and constant endeavor, The
health officers of the state first issued an order that no milk
should be sold in our state that did not come from tubereculin-
tested cows; and then the city health officer wrote a letter to
each dairyman who sold milk in Louisville, telling him that
after a certain date no milk would be permitted to be sold
in our city that did not come from a tuberculin-tested cow.

At the same time an order was given that no new cows
should be brought into the herd, unless they were tuberculin-
tested, and that the dairymen should clean up their dairies
and disinfect them according to methods suggested by the gov-
ernment at Washington. In that way we have improved the
milk-supply wonderfully in our city; and have also interested
our dairymen in keeping it improved. The education to them
has been of great value. The fact is, I believe, the dairymen
usually are glad to improve bad conditions, if we tell them
how. They didn’t know how; and they welcomed somebody
who would come and say “This is wrong; and this is the
way to correct it.” Now we have dairy inspectors go to these
dairies and see that the cows are properly curried, and the
udders properly washed before they are milked, and the milk
taken to a separate place and cooled; and we try to persuade
our dairymen to bottle it at once and bring it to market in
that way.

1 think that bovine tuberculosis is very dangerous to chil-
dren, but not dangerous to adults. The children in the hot
weather are a good deal run down, no doubt, by the heat; and
the germicidal power of the blood being lower, the germs find
easy access and a location in the alimentary canal of infants,
and in that way they become diseased. That is avoided in
part by having none but pure milk distributed. “The Babies’
Pure Milk Fund” is doing a good work with us, and we have
also pasteurized and certified milk, and in this way see that
the babies get only the best.

Dr. SENECA EcBert, Philadelphia: A few years ago, when
the newspapers of New York were advocates almost universally
of pasteurization of the milk, if I remember rightly, Dr. Dar-
lington, of the board of health, opposed pasteurization at the
dairy, the objection being that it gave the consumers a false
sense of security, since a considerable period elapsed from the
time the milk left the dairy until it reached the consumer,
and there was the possibility that in the time of transit the
milk might be contaminated, especially if carelessly handled.
It does seem to me that that objection can be made a very

26

strong one—that the milk can be pasteurized, and yet, if the
way be left open for careless handling on the part of the train
men or the dairy dealers in the cities, that there is chance for
danger there.

Another thing that I am glad Dr. Magruder mentioned was
the fairness of giving the dairymen and milkmen—the pro-
ducers—a higher price for the milk. It is unfair,. it seems
to me, for us to advocate this better milk, unless we are will-
ing to pay for it. Any man who knows anything about farm-
ing, knows that it is a pretty hard thing to provide the things
demanded—sanitary barns, good stock and all that—and then
to get no more than 3 cents or thereabouts for the milk. We
must educate the public to allow a higher price for the milk—
see that they understand that that don’t come into the cate-
gory of things to be cheapened in the attempt to reduce the
high cost of living. The question of inspection is the big ques-
tion and I believe that we have yet to appreciate that in
most of our large cities the cost of inspection is apparently
prohibitive. It ought not to be, but we are not getting—at
least, as far as the municipalities are concerned—as much in-
specting nor as many efficient inspectors as we should have.

Dr. G. Liroyp Macruprer, Washington, D. C.: First in re-
gard to Dr. Woodward’s observation, I do not claim paternity
of the idea of the inspection and permit system. I did claim
and do claim that the report of the committee of 1894, em-
bracing recommendation 9, quoted by me, directly caused the
passage by Congress of the law giving this authority to Wash-
ington. Hence I think it is justifiable to claim the honor of
being instrumental in the initiation of inspection.

As to Dr. Welch’s observation, I said bad milk was probably
the cause of the high death rate in hospitals. The lowest rate
occurred where little milk was used. It is a great satisfaction
that Dr. Welch has corroborated the statement that bovine
tuberculosis causes from fifteen to twenty-five per cent. of cer-
tain cases of tuberculosis in children under five years of age.

In answer to Dr. Egbert’s question, pasteurization should
take place in the city under official supervision. I spoke of
50° F. as the danger line because of the rapid growth of bac-
teria in milk above this temperature. This prompts. me to
mention the desirability of investigating the effects of freezing
milk. I shall promptly take up this question with the Secre-
tary of Agriculture. Three years ago the United States Consul
at Chemnitz reported to the State Department that a German
physician had recommended the transportation of milk in
frozen blocks, since no deleterious influence was exerted by
freezing. American officials caution against allowing milk to
freeze. These divergent views interested me at that time. I
sought without success to have them investigated at the
Hygienic Laboratory. General Sternberg, chairman of one of
the committees at the Yorktown Exposition, awarded first
premium for milk to the Virginia Polytechnic School at Blacks-

27

burg. This milk was delivered partially frozen, after trans-
portation 400 miles in jacketed cans.

The influence of this Section since 1907 on the milk problem
has been so great that I thought it desirable to report what
has been done in Washington. The symposium at Atlantic
City in 1907 on the milk supplies of several cities received
marked attention. The paper which I read at the symposium
contained observations made by officials of the Bureau of Pub-
lic Health and Marine-Hospital Service, of the Department of
Agriculture, of the Health Officer of Washington, and of citi-
zens in private life. Much enthusiasm was manifested at the
information, which showed that the government authorities
were so interested in milk and water supplies.

I had seen Mr. Loeb, Secretary to President Roosevelt, be-
fore I left Washington. Mr. Loeb stated that the President
was opposed to a department of public health, but was heart-
ily in favor of a bureau. On my return to Washington I saw
President Roosevelt and reported the proceedings of the Asso-
ciation on public health matters. He showed marked. interest.
He directed the investigation of the milk supply as requested
in the letter introduced in my paper. Many other valuable
investigations along this line have been conducted since then
by the government. Much of this interest is directly due to
the impetus given to the movement in this section in 1907.

Reprinted from The Journal of the American Medical Association
Aug. 13, 1910, Vol. LV. pp, £81-589

Copyright, 1910
American Medical Association, 535 Dearborn Ave., Chicago

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