jek ele ICN OF Jie Ao er ROB LE NI BY GEORGE LLOYD MAGRUDER, A.M. M.D. EMERITUS PROFESSOR OF MATERIA MEDICA AND THERAPEUTICS, SCHOOL OF MEDICINE, GEORGETOWN UNIVERSITY, WASHINGTON, D., C. THE \SUSGEPTIBILITY OF PERSONS, TO ATTACKS BY) DISEASE GERMS DIFFERS GREATLY. THE SUSCEPTIBILITY OF THE SAME PERSON TO DISHASE GERMS DIFFERS GREATLY FROM TIME TO TIME. AS THERE IS NO WAY TO MEASURE THE SUSCEPTIBILITY OF DIFFERENT PERSONS, OR OF THE SAME PERSON AT DIFFERENT TIMES, IT IS DANGEROUS FOR ANY PERSON TO EXPOSE HIS HEALTH TO DISEASE GERMS AT ANY TIME. EXPERIENCE HAS SHOWN THAT INFANTS AND INVALIDS ARE EX- CEPTIONABLY SUSCEPTIBLE TO THE ATTACKS OF DISEASE GERMS ; HENGE THEY, ABOVE ALL OTHERS, SHOULD HAVE PURE, CLEAN, GERM-FREE MILK. , 1913. PUBLISHED BY R. BERESFORD, 605 F STREET, N. W. WASHINGTON, D. C. COPYRIGHT, 1913, By GEORGE 1L.LOYD MAGRUDER, A. M., M. D. Price, 10 Gents. S XN % DEPARTMENT OF AGRICULTURE. OFFICE OF THE SECRETARY. WASHINGTON. January 25, 1913. Dr. G. Lloyd Magruder of Washington, D. C., is peculiarly qualified to write a publication on milk. The people should have pure water and pure milk. Dr. Magruder is identified in the City of Washington with a thorough study of both. He stands high as a medical practitioner and instructor, and whatever he offers to the public is certain to be well worth reading. JAMES WILSON, Secretary. ©cl.a334290 Tee 7 MILK UNDER THE GUISE OF ITS INNCCENT WHITE COLOR OFTEN HIDES THE PRESENCE OF DANGEROUS GERMS. Milk must be produced by healthy cows. Milk must be clean. Germs are few in clean milk. Milk must be promptly cooled and kept cold. The growth of germs is checked by cold. $ Milk must be properly pasteurized, promptly cooled, kept cold and covered until delivered to the consumer. These conditions secure absolutely safe milk. These conditions, without pasteurization, secure reasonably safe milk. Milk delivered in good condition to the consumer soon spoils unless kept covered and cold. Dirt and germs in milk are danger signals and warnings against raw milk. Many diseases are caused by bacteria. Bacteria in milk are made harmless by heat. Water with 2,000 bacteria to the teaspoonful or with colon bacilli is sus- picious, and should be boiled before being used for drinking purposes. Everybody knows that a water supply contaminated with sewage is a dan- ger to Public Health. Much market milk is more contaminated with germs than the sewage of many large cities. CONTAMINATED MILK IS MANY TIMES MORE DANGEROUS THAN CONTAMINATED WATER, BECAUSE DISEASE GERMS WHICH WOULD STARVE IN WATER RAPIDLY MULTIPLY IN MILK. Typhoid Fever is so rare in Munich, a city with a good water supply, well sewered and where all milk is boiled, that medical teachers are hardly able to secure subjects for demonstrating the disease to medical students. Bacteria are not removed from milk by filtering. The price of milk to the producer and the distributor should be determined by the cream, solid contents and the purity. The purity is deter- mined by the character and number of bacteria in it. Excessive numbers of bacteria show that milk is old, dirty, or produced under improper conditions or by unhealthy cows. Fortunately the public is heeding the teachings of sanitarians and is seek- ing protection by purchasing milk from producers and deaiers who recognize that milk must be free from an excessive number of any bacteria and from all disease-producing germs. SAFE MILK SAVES BABIES AND DIMINISHES THE PREVALENCE OF TUBERCULOSIS, TYPHOID FEVER, DIPHTHERIA, SEPTIC SORE THROAT AND OTHER DISEASES. INTRODUCTION. Today there is not a shade of doubt that impure raw milk and cream are prominent factors in keeping up the prevalence of Tuberculosis, Typhoid Fever, Scarlet Fever, Diphtheria, Infantile Diarrhea and other diseases and impaired physical conditions that have been positively traced to Contaminated Milk. The continued high mortality of adults and infants from these pre- ventable diseases can be enormously reduced by heeding the teachings of modern sanitarians. ‘This education must commence at the farm, and be continued to and include the consumer. ‘There must be cooperation by every one who handles milk to protect it from contamination. The public must pay for this care. The farmer must give a better product for the increased price that he must receive. Dirty milk should not be bought at any price. It is the object of this booklet to show the farmer and the consumer why safe milk is necessary and how it can be secured. During the last few months the subject of the Dangers from Con- taminated Milk and the Methods of Prevention have attracted unusual attention from physicians and others interested in the conservation of the public health. It is now generally conceded that clean, cold and properly pasteurized milk is one of the important means, if not the most important factor in reducing disease and death. ‘These conditions furnish safe wulk for everyone. It is the easy and safe soLuTrIoN of the MILK PROBLEM. To secure this much-desired safe milk vigilance is required from the farm to the consumer. Fortunately, these requirements are simple and can be complied with at small additional expenditure of time and money. Circulars 131 and 170, Bureau of Animal Industry, Department of Agri- culture, positively confirm this statement. Both time and money are necessary and must be supplied. The addition of one or two cents a quart should furnish every safeguard. “Milk at nine cents a quart should come from herds that do not show any physical signs of disease upon careful and frequent inspection, and it should be clean, cold and properly Pasteurized. Milk at 10 cents a quart should insure the additional safeguard of being furnished from tuberculin-tested cows, and being properly capped to protect against dust. The farmer should receive a due proportion of this increase in price. No safe milk can be produced under the conditions and at the prices that prevailed previous to 1907, the date that the Washington Milk Con- ference demanded better conditions and recommended the advances in the price of milk. Since then it has been repeatedly shown that the addi- tional price of one cent per quart to the farmer will secure high-grade milk with very low germ contents. Encouraged by the reception of my writings and addresses, the results of my former efforts in behalf of pure water and pure milk, and the influence for good of the work done here in Washington by persons in 5 official and private life, it seems that the time is opportune for presenting in everyday language the facts in regard to milk, that the dangers may be understood and the remedial measures may be applied. This is desirable because even yet, notwithstanding the indisputable evidence that has been presented, there are many persons of intelligence who seem to ignore these dangers and still use and permit those under their charge to use poisonous milk. This is notable in schools, hospitals, infant asylums and hotels and other eating places. Many publications relating to milk have been issued by the Govern- ment. They can be secured from the Government Departments, Mem- bers of Congress and the Superintendent of Documents, Government Printing Office, Washington, D. C. These publications have been pre- pared by persons in public and private life, sometimes as monographs and sometimes by conjoint work. They have had a world-wide influence for good. They frequently have served as the basis for national, state and municipal authorities in framing legislation and regulations for the proper production and distribution of milk and dairy products. They are repeatedly quoted by writers in this country and abroad, and have furnished most valuable data for them. SOME GOVERNMENT PUBLICATIONS IN REGARD TO MILK. Six of the most important of these publications, with the issue of which I was intimately associated, are: 1. “Report on Typhoid Fever in the District of Columbia,” submitted by the Medical Society of the District of Columbia to the Committee on the District of Columbia of the United States House of Representa- tives, June 14, 1894, and published by Congress as a congressional docu- ment in 1894. This report was prepared by a committee, appointed upon my motion, and of which I was chairman. The conclusions and recommendations of the Committee of 1894 are accepted as authoritative today. Recommendations 9 and 10 attracted much attention. Recommendation 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 exami- nation at the dairies of all possible sources of infection, including the water supply.” Recommendation 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 disinfection of the stools is the first duty of the physician as guardian of the health of the community.” The results of this report were that the District Commissioners and Congress sought the aid of the Medical Society and individual members in framing the law governing the milk supply of the District. The present attention given the pollution of water by sewage, and the contamination of oysters, thereby accentuates the Committee’s recom- 6 mendation to promptly and thoroughly disinfect the discharges from typhoid-fever patients. “ Sanitary Milk Production.” Report of a Conference appointed by the Commissioners of the District of Columbia. Issued August 20th, 1907, by the U. S. Dept. of Agriculture, as Circular 114, Bureau of Animal Industry. ‘This Conference was called upon the suggestion of Mr. E. Berliner and with my cooperation. The report was published, at my request, by the Department of Agriculture. This circular contains the Melvin Classification for Milk, and is fre- quently quoted, and has time and again served as the basis of State and municipal regulation and legislation. The London Lancet, 190%, Vol. II, No. 13, says (alluding to Circular 114) : “This volume will be the recognized text-book of the health authorities of this country for the present. * * *” 3. “ Milk and its Relation to Public Health.” Issued Jan., 1908, by the Treasury Department, as Bulletin 41, of the Hygienic Laboratory of the Bureau of Public Health (revised Jan., 1910, as Bulletin 56). This publication is the direct result of my personal appeal to Theo- dore Roosevelt, then President of the United States. It is looked upon as the most complete work ever published on milk. The New York Medical Record considers Bulletin 56 as the most valuable work ever issued by the Government on health matters. It was the conjoint work of the Bureau of Public Health, the Department of Agriculture and the Health Officer of the City. It shows the great value of cooperative work. In June, 1909, the Secretary-General of the International Institute of Hygiene told me, in Paris, that “this Bulletin was the best book in the world upon milk.” The Countess of Aberdeen, during her recent visit, stated to me that “ Sir William Osler had informed her that Bulletin 56 would give her all needed information upon the milk problem.” 4. “ The Dissemination of Disease by Dairy Products and Methods of Prevention.” Issued April 28th, 1910, as Circular 153, Bureau of Animal Industry, Department of Agriculture. This publication is the amplification of the paper which I presemied at the International Medical Congress at Budapest in 1909. This circular has also been highly esteemed and has helped to secure appropriate legislation governing the milk supply. The London Lancet, June 25th, 1910, pp. 1768, 1769, in an editorial upon Circular 153, says: “The Circulars of the Department of Agriculture have one special feature in common apart from their high scientific value, and that is their clearness. * This report is of particuar interest in that it shows how strong is the feeling in Oe ae circles in America as to the danger of contracting tuberculosis from m1 “Report of the Commission on Milk Standards appointed by the New York Milk Committee.” Reprint from Public Health Reports. Issued May 10th, 1912. This Commission was appointed as the result of a motion submitted by Dr. E. C. Schroeder, Mr. E. Berliner and myself, at the Conference in New York called by the New York Milk Committee December, 1910. This report shows that the Commission amplified the Melvin Classifica- tion adopted by the Washington Milk Conference in 1907. A majority 7 of the Commission was in favor of pasteurization of the entire milk supply. ‘This Commission was composed of some of the most prominent Serene of this country. “ Report of A Special Committee appointed by the Washington Ghammber of Commerce to investigate the Milk Situation in the District of Columbia.’”’ Senate Document No. 863, 61st Congress, 3d session. This is a most valuable work and is full of authoritative information. The last five publications, all issued during and since 1907, give an idea of some of the ‘health activities of the United States Government in relation to the milk supply. They show the promptness and readiness of the officials of the Department of Agriculture and the Bureau of Public Health to codperate for the public welfare. Millions of copies of these and other most valuable Bulletins and Circulars of great educa- tional value towards controlling and eradicating preventable diseases and conserving the purity and abundance of food supplies have been pre- pared and issued by officials of these two Departments, as well as other Departments of the Government. FREE USE OF SAFE MILK ADVOCATED. Ail the warnings as to the necessity of care in the use of ordinary market milk have been fully justified and the use of it was properly restricted. Now, if the teachings of today are heeded, unlimited use of it can be resumed with mutual advantage to the producer, distributor and the consumer. The farmer and the distributor must be paid for their efforts to comply with modern requirements. ‘The consumer will receive safe milk for his additional outlay. The additional outlay by consumers will be much less than the cost of sickness and funerals caused by unsafe milk. MILK AS FOOD. MILK AND Its Propucrs—cream, ice-cream, butter, buttermilk and cheese—are among the most important articles used for human food. They furnish quite one-sixth of the food used by mankind. The pro- ducts are liable to the same risks of contamination as milk itself, hence are equally dangerous when contaminated. Milk is the most generally employed article of diet for infants aid children. It is extensively used in homes and hospitals as a part or the © whole of the diet for the well and the sick. CONSTITUENTS OF: MILK. Mik FuRNISHES THE ELEMENTS essential to the sustaining of life and the growth of the body. ‘These ingredients are the protein com- pounds, fats, carbo-hydrates and mineral matters. Protein Compounns are the albuminous contents—casein or curd, lactalbumin and lactglobulin. They correspond to the lean of meat and the white of eggs. ‘They make muscle, bone and blood. ‘Tue Fat, after standing, rises to the surface and is known as cream. This corresponds to the fat of meat and oil. It yields heat and muscular power. 8 THE CARBO-HYDRATE is present in the form of milk sugar. It corre- sponds to the starch of cereals, and, like the fat, yields heat and muscular power. THE MINERAL Marrer is composed of combinations of lime, potash, sodium and other chemical elements, which are’ essential for the building of the human body. ' CARRIER OF DISEASE. For years physicians and others interested in the public health have demonstrated that this beneficent fluid also was a carrier of disease. Repeated appeals were made to national, State and municipal authorities to remedy this condition. As early as 1873 Congress was urged by the authorities of the District of Columbia to provide for inspection to improve the milk supply of the city. These appeals to the authorities apparently fell upon deaf ears until the summer of 1894. It is true, the year before, 1893, Dr. Coit, of Newark, N. J., did succeed, after repeated efforts for several years preceding, in inducing the State Medical Society of New Jersey to appoint the Essex County Medical Milk Commission. This Commission arranged with the proprietor of a dairy to produce milk according to the requirements and under the supervision of the Commission. This milk was known as “ Certified Milk.” Milk commissions are voluntary associations formed for the purpose of securing better milk for infants and invalids. ‘There are now in the United States 72 milk commissions. The requirements for certified milk are ideal. Constant vigilance by the highest grade of intelligent em- ployees is essential to carry out these requirements. ‘This vigilance is not obtainable for lengthly periods. With all precautions exercised, there are frequent reports of contaminated milk being served by certified dairies. This is true to so great an extent that many prominent members of the Association of the American Medical Milk Commissions, who formerly believed that raw milk was a much better food for infants and invalids than pasteurized or boiled milk, now openly admit that no milk is safe for use until after it has been exposed to a sufficient degree of heat to kill disease germs. The influence of medical milk commissions in securing an improvement in the general milk supply has been very great, exceptionally so since the organization in 1907 of the Association of American Medical Milk Commissions. Unfortunately the requirements for producing certified milk are so exacting that the cost of the product is beyond the means of the masses. THE MILK LAW OF 1895. The first important step in the legal control of the milk supply was initiated in Washington in 1894. It required the occurrence of cholera in Hamburg and its appearance upon a ship from that port in the harbor of New York to arouse the attention of Congress to the dangers lurking in milk. This resulted in the passing of the law, approved March 2d, 1895, which provided that no milk should be sold in Washington without 9 a permit from the Health Officer, and that such a permit should not be issued until after an inspection of the conditions at the farm, including the water supply. These requirements were those suggested in Recom- mendation 9 of the report made the year before by the Committee of the Medical Society upon the Causes and Prevalence of Typhoid Fever. This law gave Washington the honor of being the first city in the coun- try, if not in the world, to have legal requirements for its milk supply. WHY SAFE MILK IS NECESSARY. Chemical examinations and bedside observations had shown, time and -again, that milk was the cause of serious outbreaks of a number of diseases and the increased death rate therefrom. It was also shown that malnutrition, disease and death also resulted from much of the milk used for infant feeding. RESULTS OF BACTERIOLOGICAL INVESTIGATIONS OF MILK. To bacteriology, which by this time had made great progress, the world is indebted for the positive knowledge of the .causes of many diseases. Bacteriology has shown that these diseases are the direct result of spe- cific bacteria. Bacteria grow with amazing rapidity in milk, since milk furnishes the most favorable conditions required for their growth. Bacteria are commonly known as germs. They belong to the vegetable kingdom. In fact, they are minute plants which cannot be seen without the aid of a powerful microscope. ‘They appear in nature in three forms, the spherical, the rod-like and the spiral. The spherical are commonly known as cocci, these include the streptococcus, the staphylococcus and other cocci. The rod-like group are called bacilli, and include the typhoid, tubercule, colon and diphtheria bacillus. The spiral group are called spirilla and spirochaeta: Bacteria, like visible plants, may be harmless or deadly. We have the harmless and nutritious mushroom and the deadly toadstool. We have the harmless and valuable nitrogen-producing bacteria which contribute so much to the growth of plants and the deadly germs of tuberculosis and typhoid fever. GROWTH OF BACTERIA. Under favorable conditions bacteria attain maturity within an hour. Milk is an ideal medium for'their growth. Their multiplication is accom- plished by the simple process of transverse division, that is one bacterium becomes two, two become four, four become eight, and so on indefinitely. Bacteria do not grow rapidly in pure water, but they do survive in it for various periods and promptly grow when subjected to favorable conditions. ; In Raw Market Mik as many as one billion and a quarter germs have been found in a single teaspoonful. The sample was taken from a wagon on a regular round in the summer-time. In a level teaspoonful of ice cream over two billion germs have been found. Imagine the pos- sible result if many of these had been disease-producing bacteria! \ 10 Below 50 degrees F. the growth of many bacteria is checked, but they survive even below the freezing point. Above 50 degrees F. they begin to multiply and multiply with marked rapidity as the warmth increases. When the temperature increases above 100 degrees F. the various Culture plate from milk carefully drawn Culture plate showing bacteria in milk not from washed cow, handled in a sanitary man- cooled, kept at 60°F. for twenty-four hours. ner and kept at 50° F. Only a single colony, Numerous colonies; 2,800,000 bacteria per and but 500 bacteria per cubic centimeter. cubic centimeter. varieties begin to die. As the result of investigations by men of the highest authority the world over, it has been found that all disease-pro- ducing germs commonly present in milk, technically called pathogenic, are killed at a temperature of 140 degrees F. maintained for twenty minutes. This degree of heat and time of exposure do not in any way destroy either the chemical or nutritive properties of milk, nor do they alter the taste, nor do they destroy the cream line. There is no per- ceptible alteration in the milk. OFFICIAL INVESTIGATION OF THE EFFECTS OF COLD AND HEAT UPON MILK. The Department of Agriculture is at present conducting an investiga- tion into the effects of temperature, from the freezing point and below to the boiling point, as to the chemical and nutritive properties of milk. The report of this investigation will be of great value. German authori- ties have claimed that no ill effects have resulted from freezing milk. Information available in the Bureau of Animal Industry confirms the claims of the German authorities and of the above facts as to the influence of heat at 140 degrees F. for 20 minutes. ; SOURCES OF BACTERIA IN MILK. Men of high authority on the properties of milk maintain that milk may be. free from bacteria when secreted from the healthy cow. Milk is rarely, however, found free from bacteria. Disease or injury to the 3H) 6 udder or bag of the cow is accompanied with the presence of bacteria. Some diseases of cows are accompanied with the discharge of germs in the milk. Bacteria even penetrate into the small openings of the cow’s teat, but do not extend very far into the udder. The possible danger of contamination from this source can easily be largely averted by not collecting the first few streams of milk, which is known as fore milk. The contamination of milk occurs from many outside sources: dirt and dust in the air of the stables, dirt and dust from the body of the cow falling into the milk pail, and dirt from the clothing and hands of the milkers. This dirt and dust convey many bacteria: the dirt from the body of the cow is exceptionally dangerous, as much of it is cow manure, and the dirt from contaminated pools in the barnyards and pastures, which con- vey to the milk the colon and streptococci germs. The colon bacilli in- variably comes from the intestinal canal of man or beast. Their pres- Dirty sediment in bottom of bottle of milk. Milk sediment magnified. This sediment consists of cow dung, hair, bacteria, etc. ence indicate contamination with fecal discharges. Recent studies have demonstrated the existence of virulent bacteria stored under the finger- nails of persons handling food products. Keeping the nails short, and careful washing of the hands with the nail brush before milking, will eradicate this source of infection. Flies are a common source of con- tamination. From the habits of the fly this source of contamination is most dangerous. Screens should be used to prevent access to privies and thence to milk houses. THE Pais, CANS AND Bort.es used in the process of preparing and distributing milk are a constant source of contamination. Unless, before being used and being filled, these are scrupulously cleaned with boiling water, a potent source of contamination is furnished. Cold water should never be used in the final cleansing of milk utensils. A visit to the average distributing depot or dairy will show that here, too, are mani- fold and prolific sources of milk contamination. 12 BACCILLUS CARRIERS. - Bacteriology has shown within the last few years that persons fre- quently carry in their systems germs of the disease for years after having recovered from a germ disease. Cases are on record of severe out- breaks of typhoid fever being traced to handlers of milk who had had the disease many years before. Such persons are known as “ Baccillus Carriers.” It is also true that many persons have been known to harbor virulent bacteria of diseases, such as diphtheria, pneumonia and others, without ever having suffered with the disease themselves. Fortunately, the human system is endowed with powerful resistance to the attacks of harmful bacteria. Jt is when this resisting power is low that direful results ensue. THE WATER SUPPLY OF DAIRY FARMS. In the fall of 1906, at my request, bacteriological investigations, the first extended series of their kind on record, were made of the water supplies of 60 dairy farms, taken, without selection, in Maryland, Vir- ginia and the District of Columbia, by the Department of Agriculture. The revelations of contamination were startling. In the winter and spring of 1907 290 more water supplies were examined with equally astounding results. The bacteriological examinations of the water supplies of the first 60 dairy farms showed that only 25 per cent. were under the danger line—that is, if we take 500 bacteria to the cubic centimeter (15 drops) of water as the limit of safety, 30 per cent. were suspicious, having above 500 bacteria to the cubic centimeter, and 45 per cent. were unfit for use, as they showed the presence of sewage bacteria. The bacteria counts in some instances were as high as 27,000, though they were made in November and December—that is, in comparatively cold weather. Since these bacteriological examinations were made similar examina- tions have followed in other cities, with almost identical results. No community would permit the use for any extended period of a contaminated water supply. Every careful householder should boil the water until remedial measures were furnished. Millions have been spent to purify water supplies of cities. Why should not the same concern be exercised in regard to a contaminated milk supply? The dangers are far greater. In the Report of the Secretary of Agriculture for 1912, on page 139, it is stated: “Simple directions for the improvement of farm-water supplies have been formulated.” ‘This is a most important and valuable announcement. DISEASES PRODUCED BY CONTAMINATED MILK. It has been found that a number of diseases, namely, Tuberculosis, Typhoid Fever, Septic Sore Throat, Diphtheria, Scarlet Fever and Intestinal Disorders of Infants, have been positively traced to the germs found in milk. Some of these have been derived from the cow, others have found their way into milk through human agencies. It will suffice to consider some of these germ-produced diseases. 13 TUBERCULOSIS. TUBERCULOSIS is the one disease the germs of which enter milk almost exclusively from the cow. Upon rare occasions the germ enters the milk from the coughing, sneezing or carelessness of a milker affected with the disease. Tubercle bacilli are secreted in the milk when there is tuberculous disease of the udder. Frequently milk is found contaminated with tubercle germs for some time before the disease is detected in the cow from which the milk was obtained. ‘The commonest source of con- tamination is in the discharge from the bowels of cows affected with the disease. This cow dung falls into the pail from the flanks, udder and tail of the cow at the time of milking. They do not multiply in milk, but they do survive and do grow when subjected to favorable conditions. Neither the processes of making ice cream nor butter destroy them. Schroeder found them virulent for guinea pigs in butter made from contaminated cream, which butter had been kept in storage for 161 days. Three out of four hogs, weighing over 150 pounds, fed two ounces of butter per day for thirty days, were found to have contracted tubercu- losis. Butter from raw cream is often contaminated with tubercle germs. Cream is found to have many more germs than milk, since the germs adhere to the fat globules and rise to the surface with them. The Department of Agriculture found tubercle germs in the refuse from the separators in 33 per cent. of the creameries examined. This start- ling revelation warns that skimmed milk should not be used for man nor beast in a raw state. Tubercle bacilli are frequently found in market milk. The Bureau of Animal Industry has shown that from five to tweaty-five per cent. of dairy cows responded to the tuberculin test. Tests made in 1907 of a large proportion of the herds supplying milk to Washington showed that 17 per cent. of the cows reacted. To Robert Koch we are indebted for the discovery that the Great White Plague, in its various manifestations in man and beast, is due to a germ known as the tubercle bacillus. For years he maintained ‘that the germs for man and beast were identical. In 1901 he promulgated his opinion that the bovine tubercle bacillus was harmless to man. At once this statement aroused great interest. Numerous investigators gave much study to the question. Now it is almost unanimously maintained that this opinion, announced by Koch in London in 1901, and reiterated at the International Congress on Tuberculosis in Washington in 1908, was wrong. The work of Schroeder and Cotton on this subject attracted universal attention. (See Bulletin 99, May 11th, 1907, and Circular 118, Dec. 21st, 190%, Bureau of Animal Industry, Department of Agriculture.) They demonstrated that tuberculous cattle discharged tubercle germs from their bowels; that these germs have their origin principally in the lungs, are coughed up, swallowed and then discharged in still virulent form with the feces. They also demonstrated that “ The cattle that pass tubercle bacilli per rectum are not always visibly diseased. Many ap- parently healthy but tuberculous cattle which are not known to be tuberculous until they are tested with tuberculin, intermittently pass tubercule bacilli from their bodies per rectum with their feces.” 14 Some of these cows were affected with tuberculosis of the udder and secreted tubercle bacilli in their milk. Several hundred guinea pigs were inoculated with this milk in a raw state. Every one of them showed general tuberculosis. Over 200 guinea pigs were injected with milk from the same cows after it was pasteurized for 20 minutes at 140 degrees F. Not one of these showed any signs of tuberculosis. The investigations made relative to the use of pasteurized milk from tuberculous cows and from cows actually affected with udder tubercu- losis, prove that it has no objectionable influence on the body and that it does not injure the health in any determinable way. The safety secured by pasteurizing the milk is a very important fact from an economic standpoint. The milk of every one of these apparently healthy cows could be used with absolute safety in the raising of children, calves and hogs, and for household purposes after being brought to and held at the proper heat for the destruction of the tubercle germ. No An apparently healthy but dangerously tuberculous cow. Her milk, after it has been properly pasteurized, is safe. Hence it is not necessary to kill her. complicated apparatus is necessary to accomplish this much-desired re- sult. What a boon to mankind if this fact would be accepted and applied! The farmer, in time, would thus. secure a healthy herd and healthy hogs. His resources would be promptly augmented. There would be less de- struction of live stock and condemnation of food products derived from this source. The experiments and conclusions derived therefrom by Schroeder and Cotton have been repeatedly confirmed. “The practica- bility of eradicating bovine tuberculosis and of building up herds of sound animals from the progeny of tuberculous cattle was demonstrated at the Ohio Experiment Station of the Department of Agriculture. (Report of Secretary of Agriculture, 1912, page 99.) The British Royal Commission to inquire into the relation of human and animal tuberculosis confirmed the experiments of Schroeder and Cotton in every particular, and so reported 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 January 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: t5 “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 trans- mission of the disease from affected bovine animals to man, the board are satis- fied 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 concur 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 tubercu- losis by the means of milk used for human consumption. “Tn considering the question in relation to animals, the fact that the disease is communicable to man by milk has a material bearing on the measures to be adopted. Any action which results in the reduction in the number of tubercu- lous bovine animals in the, country must reduce the risk of the spread of tuber- culosis 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 campaign against the disease in man.” The position of the British Royal Commission as to the material bene- fit to mankind of the control of the tubercle germs in milk is sustained and strengthened by the data taken from a publication of the Research Laboratory of New York City, based on 1,220 cases of tuberculosis examined by Park and Krumweide. The following table graphically shows the data: PERCENTAGE FREQUENCY OF TUBERCULOSIS CAUSED BY INFECTION WITH TUBERCLE BACILLI FROM TUBERCULOUS Cows. Adults | Children | Children Diagnosis. 16 years 5 to16 | under and over. years. 5 years. per cent. ’ per cent. per cent. Pulmonary tuberculosis, .) gsi. (b. 0.0 0.0 | 4.1 Tuberculosis adenitis, cervical, ... . 3.6 36.0 58.0 Abpaominal tuberculosis; \ 3272. 1. 22.0 46.0 59.0 Generalized. tuberculosis, 600-0522." 27 “; 40.0 23.0 Tubercular meningitis (with or with- out generalized lesions), ...... 0.0 0.0 13.6 Tuberculosis of bones and joints, .. . ainpee eae 0.0 Reliable evidence has shown that more than 25 per cent. of all cases of tuberculosis in children under 16 years of age are of bovine origin, and 121% per cent. of fatal cases of tuberculosis among children under five years of age are due to bovine tubercule bacilli. These facts have so impressed thé authorities of France that it has been recommended, with a view of. saving the infants of France from tuberculosis and diarrhoel diseases, that all milk be heated to 176 degrees F. Disease germs in milk heated to 176 degrees F., even for a few minutes, will be killed. 16 There are the disadvantages that at this temperature the cream line’ is destroyed and the milk acquires a cooked taste. ‘The available evidence gives us no reason to believe that these changes are accompanied by a lessening of the food value or the digestibility of the milk. This tem- perature of 176 degrees F. has been selected because it is known to be beyond the death point of disease-producing germs, and a test is available to ascertain promptly whether such a temperature has been used with the milk. The test is derived from the fact that the chemical Para- paphenylenediamine (for short, called the Para Test) immediately changes the color of the milk to blue, if it has not been heated beyond 175 degrees F. , The Washington Association for the Prevention of Tuberculosis gave especial attention to milk as an important phase of the tuberculosis situa- tion at two meetings in 1912. Strong resolutions positively endorsing the necessity of the pasteurization of the entire milk supply by the holding process were adopted. Amongst others, the following persons discussed and voted for the resolutions: George M. Sternberg, Surgeon General, U. S. A., Retired; Dr. Harvey W. Wiley, Chemist and Chief Bureau of Chemistry, U. $. Department of Agriculture ; Dr. E. C. Schroeder, Superintendent Experiment Station, Bureau of Animal Industry ; Dr. R. W. Hickman, Chief of Quarantine Division, Bureau of Animal Industry ; Dr. George M. Kober, Professor of Hygiene and Dean of Georgetown University Medical School ; Mrs. John McLaughlin ; Dr. Jesse Ramsburgh ; Dr. A. D. Melvin, Chief of Bureau of Animal Industry, U. 5. Depart- ment of Agriculture ; Dr. John R. Mohler, Chief of Pathological Division, Bureau of Animal Industry ; Dr. Wm. C. Woodward, Health Officer, District of Columbia ; Dr. G. Lloyd Magruder, Emeritus Professor of Materia Medica and Therapeutics, Georgetown University ; Dr. Wm. C. Gwynn; Mr. Emile Berliner, and other prominent sanitarians. In face of this mass of most authoritative evidence in England, France and this country, should not the recommendations as to pasteurization at once be heeded and steps taken to eliminate the dangers so imminent in milk ? Inthe year 1912, according to the estimates of the National Association for the Study and Prevention of Tuberculosis, nearly nineteen million dollars ($19,000,000.00) were spent for the support of patients in sani- toria and hospitals. Spend more money to enable health officers to secure competent employees to disseminate the importance of safe milk throughout the land, and the funds necessary for hospitals, asylums and sanitoria, will be decreased rapidly in much greater proportion than the 17 initial outlay to add to the efficiency of the efforts of health officers A great step will be made towards eradicating the Great White Plague, which is universally held to be a preventable disease. SEPTIC SORE THROAT. _ In the last three or four years Bacteriology has added important addi- tional data to the dangers from contaminated milk. Repeated outbreaks of virulent sore throat accompanied with high mortality have been traced to the presence in milk of a streptococcus. This streptococcus may get into the milk from a human source or from the presence of streptococci in diseased udders. The occurrence of over 600 cases of sore throat in Stockholm in the year 1908, was traced to a streptococcus abcess in the udder of a cow in a herd that furnished milk to those who became infected. The char- acteristics of the two streptococci were identical. Since this outbreak in Stockholm careful study has been made of a number of such outbreaks in Chicago, Boston and Baltimore. Uniformly has the cause been traced to the presence of a streptococcus. It has been found that the disease does not stop at the throat. Serious diseases of other parts of the body, as the heart, the brain and the joints, have been traced as resulting from the throat infection. Most exhaustive study was given to the outbreak in Boston in May, LOU Sedgwick, Winslow, Rosenau, Prescott and many others took part in the investigations. The investigation by Winslow was most thorough. He found the cause to be a streptococcus, and traced the origin to the most carefully conducted dairy in Boston. There were cases of sore throat in a family on one of the farms that supplied milk to the dairy and also in a family of one of the employees at the dairy. These outbreaks of septic sore throat furnish a most powerful argu- ment for the pasteurization of the entire milk supply. It is reported that now all milk furnished by this dairy in Boston is properly pasteurized in the final container. The Baltimore epidemic was studied by Dr. Frost, of the Bureau of Public Health. He found that this outbreak was also due to a strep- tococcus, which survived flash pasteurization. The outbreak ceased as soon as proper pasteurization was installed at the dairy plant. Much study is now being given to the significance of streptococci in milk. PYETIOR FEVER. Germs of.typhoid fever grow with amazing rapidity in milk and soon increases the danger arising from this infection of milk. A few germs will soon multiply to such an extent that the whole supply with which it comes in contact will be contaminated. Mohler and Washburn found that the typhoid bacillus survived 21 days in milk kept sweet and 151 days in butter kept in cold storage. This draws attention to the fact that the variety of germs in milk is more to be considered than the actual numbers. 18 Typhoid germs enter milk entirely from sources outside of the cow. The cow’s flank and udder may become infected from the cow having waded in streams polluted with the discharges from fever patients The washing with cold water of the utensils used in the handling of milk is a prolific source of the germs. ‘The fact that typhoid fever is eminently a rural disease, occurring two and a-half times more fre- quently in the country than in cities, and the known contamination of the water supplies of farms, point to the necessity of exercising great care to avoid these sources of danger. In two counties in Maryland, large milk producing counties for Balti- more and Washington, there were 33 deaths from typhoid fever in the year 1905. Counting 10 cases to a death, there were 330 cases of typhoid fever in these counties—a serious menace to these two cities. Everyone is familiar with the common custom, in the country, of throwing the discharges of the sick, without proper disinfection, upon exposed places, from which they may be washed into the nearby water supplies, or permit flies easy access thereto, which carry the germs to and infect the pails of milk. The milkers and handlers of milk also infect the milk. They frequently have the disease for days before being compelled to take to bed. Typhoid fever is a disease that is especially spread by germ or bacillus carriers. In the fall of 1908 over 50 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. Many reports of outbreaks due to this case have been made in this country and Europe, and are being made with increased frequency. The contention for pure water, pure milk, and the avoidance of con- tact, outlined in 1894, as preventive measures against typhoid fever, is further sustained in Bull. 44 of the United States Public Health Service, as follows: “Thus far our studies indicate that typhoid fever will cease to be a problem in any community having clean water, an uninfected 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 advisory board of the hygienic laboratory, composed of eminent scientists and sanitarians.” ADVISORY DOARD. Prof. William H. Welch, Johns Hopkins University, Baltimore, Md.;. Prof. Simon Flexner, Rockefeller Institute for Medical Research, New York; Prof. Victor C. Vaughan, University of Michigan, Ann Arbor, Mich.; Prof. William 'T. Sedgwick, Massachusetts Institute of ‘Tech- nology, Boston, Mass., and Prof. Frank F. Wesbrook, University of Minneapolis, Minn.; Lieut. Col. Walter D. McCaw, Surgeon, U. 5. Army; Medical Inspector. FE. R. Stitt, U. S. Navy; Dr. A. D. Melvin, Chief of U. S. Bureau of Animal Industry, and John F. Anderson, U.S. Public Health Service, e+-officio. 19 EPIDEMICS TRACED ‘TO THE MILK SUPPLY. In May, 1901, Dr. George M. Kober reported a series of 195 epidemics of typhoid fever. In 148 of the 195 epidemics of typhoid fever there is evidence of the disease existing at the farm. At the same time he reported 136 outbreaks of scarlet fever and diphtheria. Kober says: “Tt is interesting to note that of the 330 epidemics analyzed by me 243 have been recorded by English authors, 52 by American, 14 by German, 11 by Scandinavian, and 5 each by French and Austrian writers. This is probably due to the fact that the English and Americans usually consume raw milk, while on the Continent the milk is rarely used without being boiled.” Surgeon Trask, of the United States Public Health and Marine Hos- pital Service, in Bulletin 56, has added a large number of similar out- breaks to Dr. Kober’s list. Edward O. Jordan, of Chicago, in an address before Section VI, International Congress on Hygiene and Demography, in September, 1912, has added a large number of similar outbreaks. In an interview with Mr. E. Berliner, of Washington, Dr. Heineman, the Health Officer of Cassel, Germany, reported the occurrence of over 300 cases of typhoid fever in the summer of 1909, as the result of the use of contaminated raw milk. Boston had an outbreak of 1,000 cases of typhoid fever in 1908 from a single source of contaminated raw milk. In the summer of 1910 nearly 500 cases occurred in Budapest, Hun- gary. These were traced to infected raw milk. In 1890 there occurred in City of Washington 135 deaths per 100,000 of population from typhoid, so-called typho-malarial and malarial fever combined. It is safe to say that these deaths were nearly all from typhoid fever. The population then was nearly 300,000. Assuming the usual proportions of 10 cases to one death, there were nearly 4,000 cases in Washington in 1890. In 1912, with a population of 354,000, there were but 585 cases with 78 deaths, giving a ratio of 22 per 100,000 of population. The diagram prepared for me by the courtesy of Dr. MorRTALITY FROM TYPHOID FEVER IN THE DISTRICT OF COLUMBIA, 1890 TO I9I12, IN— CLUSIVE. AVERAGE ANNUAL DEATH RATE 4... PER 100,000 FoR FrvE-YEAR PERIODS. 00,000 G0 jen 100,000 —i Oni Qik, Orfancdk|!2, 1895 1390 - 1394. oe 1845 = 1849 1900-1904 1905 -1909 WMO 19111912, 20 Woodward, the Health Officer of the District of Columbia, graphically shows the data in regard to this disease. It is interesting to note the decrease in mortality after the passage of the Milk Law of 1895 and the work of the Milk Conference in 1907. Another factor must be considered towards contributing to the drop in mortality since 1901, both from typhoid fever and infantile diarrhcea. ‘This factor is the con- tinuous publication by Mr. E. Berliner in two of the Sunday papers of Bulletins warning of the danger of raw milk and advising home pasteurization or the scalding of milk used for infants and invalids. This appalling prevalence of typhoid fever and high mortality of infants as shown by the census of 1890 prompted me to enlist in the campaign for Pure Milk and Pure Water. THE GERM WHICH CAUSES THE PREMATURE BIRTH OF A DEAD CALE: Bacteriology has recently demonstrated that the affection of the dairy herd, long recognized as contagious to animals, is the result of a germ which has been carefully studied. In addition to causing great loss by the birth of dead calves, it has been found that it produces in guinea pigs and other animals diseased conditions of their organs, closely re- sembling those produced by the germs of tuberculosis. These germs, like those of tuberculosis, are found frequently in market milk, without any evidence of disease in the herds of cows from which the milk is supplied. Schroeder, in May, 1911, at the meeting of the Association of American Medical Milk Commissions, announced the results of the investigations made by him and Cotton. They distinctly described the germ. The work was confirmed by Theobald Smith and Fayban. ‘They reported their results in January, 1912. The discovery of this organism in milk, since there is no prompt method ° of recognizing it, furnishes an additional argument for the proper pas- teurization of all milk. It, too, like the other disease-producing germs frequently present in milk, is killed when exposed to a temperature of 140 degrees F. for twenty minutes. EFFECTS OF CONTAMINATED MILK UPON INFANTS. There is no specific germ that causes malnutrition and the gastro- intestinal troubles of infants. It is the general observation that the presence of streptococci and colon bacilli in milk does augment these disorders. Excessive numbers in milk of any germ, even those at times considered to be harmless, has been found also to be productive of these troubles. The presence of colon bacilli is the source of great danger to children. THe EFFECTS oF CONTAMINATED MILK have been shown by the preva- lence of diarrhoeal diseases and the occurrence of numerous cases of mal- nutrition amongst infants raised upon cows’ milk. One has but to observe the mortality tables during the summer months and compare the bacteriological reports of milk ordinarily used for mfant feeding to be convinced of the direful influence of such milk. ai For more than twenty years philanthropists, sanitarians, physicians and others interested in child welfare have been struggling to educate the public to the importance of a safe milk supply as the greatest factor in the saving of infants’ lives. The value of an improved milk supply has been strikingly shown in Washington since the passage of the Milk Law in 1895, more strikingly from 1907, when renewed activity towards the improvement of the milk supply was started, and most strikingly in 1912, when again increased activities took place. _ There was a steady improvement in the milk supply in Washington from 1895 to 1907, a more marked improvement each year since 1907. There has also been a steady diminution in the death rate of children under two years of age from diarrhoeal diseases. In 1894, the death rate was 190 per 100,000 of population, in 1912 it fell to 53. There is every -reason to believe that a much lower record would have been secured had more attention been given to the character of the milk fed to babies. MorTALITY FROM DIARRHEAL DISEASES UNDER Two YEARS IN THE DISTRICT OF COLUMBIA, I890 TO 1912, INCLUSIVE. AVERAGE ANNUAL DEATH RATE PER 100,000 FOR FIVE- Ged. jon YEAR PERIODS. Rate pr 100 000 V5 Dh Ger |Crrongh 2, 129s A407 Cana VS: yao Lk Ne area. 1890-1894 1895-1899. \900-1904. 1905-1909. V9N0, 1901, 1912. The diagram prepared by the Health Department plainly shows this steady diminution of infant mortality. This experience has prevailed whenever and wherever improved con- ditions have been secured. During 1912 cleaner milk and better pas- teurization were more general in many cities. In New York City extraordinary improvements were made. There were nearly 1,000 less 22 deaths of infants under one year of age than the year before. ‘Twenty per cent. were attributed directly to the better milk supplied at the milk stations and by the dealers. In my opinion this estimate is too conserva- tive. Supply better milk at once throughout the country and it will be seen at the end of the year 1913 that nothing like 300,000 babies will be © dead. The experience in Washington coincides with that in New York. More heed has been paid to the findings of bacteriology and greater efforts have been made to remedy the existing conditions. The progress for good from 1895 to 1907 was great, from 1907 to 1912 it was mar- velous. The movement for the improvement of the milk supply the world over has spread with amazing rapidity. The campaign of education is bearing fruit. The benefits of proper pasteurization are now admitted, More milk is subjected to the process and far better results are now ob- tained by the improved methods. It has been observed that 35 per cent. of infants admitted to public institutions die. It is also well known that hospitals and public institutions have been exceedingly careless about the milk purchased. (See Bulletin 56, Bureau of Public Health, pp. 439, et seq.) The experience of milk stations and dispensarizs, hos- pitals and homes in saving lives, where strict supervision is exercised over the raw and pasteurized milk used, should warn those in charge of institutions with high mortalities to at once carefully supervise their milk supplies. HOW MILK CAN BE MADE SAFE, Milk should be clean, cold and properly pasteurized. From the data furnished in the preceding pages it must be conceded that dairy pro- ducts are prolific causes of disease and death. ‘These facts cannot be too forcibly nor too frequently brought to the attention of the public. Per- sons of high intellectual attainments, and even physicians of superior ability, constantly ignore the conditions of the production and the distri- bution of the supphes used in their own households, as well as by their patients. Instances are many where no efforts have been made to ascer- tain the quality of the milk used. Milk can be readily made safe by the exercise of common sense and ordinary care. Milk should be clean, cold and free from disease-producing germs as well as an excessive number of other germs. The records of Health Departments of up-to-date cities will furnish information upon these subjects. ‘These records should be more frequently consulted than they are. In some progressive cities they are regularly published in bulletins — and the daily papers. The knowledge of the dangers of milk and the methods of prevention should be widely disseminated. This dissemination of knowledge should commence in the schools, espe- cially in those of rural communities. The value of safe milk ‘should also be kept before the dwellers in the cities. At the meeting of the Association of Medical Milk Commissions held in June, 1910, at St. - Louis, report was made of the splendid results accomplished at Gales- burg, Ill., by having students examine in their classes the milk supplied to their homes. This example should be followed in every city. 25 RESULTS OF INSPECTION OF DAIRIES. The authority given by the Milk Law of 1895 for the inspection of dairies has produced admirable results from an educational standpoint. This inspection has been made the means of acquiring knowledge of existing conditions at the farms and dairy depots and of imparting in- struction as to the removal of defects and the addition of appropriate improvements. Inspection has revealed many unfavorable conditions both at the farm and at the city depot. Insanitary houses, milk houses and barns were common. ‘The attendants on cattle were careless of their personal habits and were frequently suffering from disease, sometimes of a contagious character. Cattle were frequently found covered about their flanks, legs, udders and tails with manure and other dirt, which _ readily dropped into the pails while the milking was being done. Cattle were many times found to be suffering from constitutional diseases as well as local affections of the udder. Flies swarmed about the premises. paequently dead and dying flies floated on the surface of the milk in the pails. Dr. L. O. Howard, in a publication by the Department of Agriculture, suggests that the common house fly be known as the “ typhoid fly.” Re- cent experiences in Wilmington, N. C., and Jacksonville, Florida, justify this suggestion. The presence of sediment in the milk containers was a common occurrence. ‘This is especially dangerous, since it has been Colonies of bacteria transplanted by a fly’s feet. _shown that the ingredients are pus cells, blood, epithelium, barn-yard manure, and varied bacteria, including the streptococcus and colon bac~ illi. Few, if any, facilities were found for boiling the water to clean the utensils used in the handling and transportation of milk, the hands of the milkers or the udders of the cows. Polluted water readily contaminates milk. Heat destroys the pollution. A health official of Indianapolis, speaking of inspection, 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 24 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 that they did.” The experience of Richmond, Va., with inspection has been most gratifying. Inspection began in May, 1907. The average rating of the farmers was 41.5 out of a possible 100. But 15 per cent. of the dairies scored above 60. In December, 1911, not one was rated below 70. Of all supplying Richmond, 67.4 were rated between 80 and 90; 5.5 per cent. were rated above 90. In his report for 1911 the Health Officer says: “The inspector has been enabled to give sound practical advice to our dairymen, thereby assisting them in many ways. * * * Practically all our dairymen have come to regard him as a real friend and helper.” Washington City also furnishes an excellent illustration of the effects of intelligent inspection. The inspectors and the producer have learned to understand each other. Many of the farmers welcomed the criticisms and proceeded to remedy the defects, as it was found that much could be done at an insignificant outlay of time and money. Much higher ratings were given in many cases on the second inspection. As a result of this educational inspection much raw milk is delivered to the dis- tributing depots with less than 2,000 bacteria to the cubic centimeter and without either streptococci or colon bacilli. The President of the Milk Producers Association of Maryland, Vir- ginia and the District of Columbia, in one of his addresses, says: “ that the day was past when the milk inspector was looked upon as an irrecon- cilable enemy.” Such expressions show the spirit with which intelligent inspection is met. ‘The educational inspection means much to both pro- ducer and consumer. It contributes not only to the health of the families of both, but also to that of the dairy herd. THE IMPORTANCE OF THE EXTENSION OF INSPECTION AND OF UNIFORM REQUIREMENTS. Wherever intelligent inspection has been practiced satisfaction has been experienced. The American Public Health Association and the Association for the Study and Prevention of Infant Mortality at the 1912 meetings passed resolutions urging uniform ratings for the results of inspection. Many States and cities have diverse requirements. ‘This necessitates at times repeated inspections of the same dairy. Milk rejected by one city will be received by another with less rigid requirements. Uniform requirements exercised by well-trained, competent inspectors would se- cure a much more reliable product. Health officials should be qualified for their work by proper training. ‘Their tenure of office should be di- yvorced from politics, as are the United States Government Services. THE HEALTH ACTIVITIES OF THE GOVERNMENT ARE GREAT FACTORS IN SHOWING HOW SAFE MILK CAN BE SECURED. A great step forward would be made if more health officials and those interested in the public health, would avail themselves of the privilege to attend the Hygienic Laboratory of the Bureau of Public Health, as 25 well as the laboratories of the Department of Agriculture. They would soon learn of the health activities of the Government; that these activi- ties are against the causes of disease, and for their prevention; that there is no truth in the common slogan that “ the sick hog receives more atten- tion than the sick woman or child.” They would find that, in addition to the universally recognized valu- able work against disease and death of the Bureau of Public Health, a large proportion of the work of the Bureaus of the Department of Agriculture is along the same lines; they would also find that the Medical Officers of the Army and Navy are active with the problems of preventive medicine. Millions of the money appropriated for the Department of Agriculture are expended for purposes bearing directly upon the conser- vation of the public health, whilst only thousands are used for diseases of animals. They would find skilled officials ready to immediately re- spond to calls from State, county and municipal authorities for aid in forming plans for education to prevent disease and in repelling invasions by disease; that these officials have as willingly laid down their lives in He against disease as have the Army and Navy in attacks upon the ag. They would also find that Public Act No. 236, approved July 1, 1902, “to increase the efficiency and change the name of the Marine Hospital Service to the Bureau of Public Health and Marine Hospital Service,” is an excellent foundation upon which to build a Department of Public Health. This Act provides for an Advisory Board. ‘The composition of this Board, being of eminent scientists and sanitarians from the Federal De- partments and civil life, makes the Board authoritative upon public health matters. For the names of the present Board see page 18. ‘The section providing for this Board was framed with my assistance and was inserted at my suggestion. The idea of such a Board was practically endorsed in 1909 by a special committee of the National Academy of Sciences, appointed at the request of Congress. See special message sent to Congress by President Roosevelt January 18, 1909, House Document No. 1337, 60th Congress, 2d Session. The last section gives power to the President to prescribe rules for the conduct of the service. The laboratories of the Federal Departments have been the training schools for some of the most brilliant teachers, investigators and officials of the great universities, colleges, State and municipal governments, as well as experts for many private business concerns. Numerous in- vestigations in regard to the public health are constantly being con- ducted. Authority for additional men in these corps of health workers, and funds for their investigations and the publication of the results of these investigations, is imperatively needed. Congress should be gener- ous to those branches of the Government service. HOW THE HEALTH ACTIVITIES CAN BE GREATLY INCREASED. Congress, at a very little cost, can immediately multiply the benefits of Federal efforts for the public health without favoring any special school of medicine. The causes and the prevention of diseases are factors inde- 26 pendent of those points on which different schools of practice disagree. The work will soon show such great value that no one will object to an - additional Department devoted to the public health. Such a department should be evolved rather than created. The following few provisions would more or less contribute to this much needed and desired end: Provide for a Committee on Public Health in the House of Represen- tatives ; Provide that the Advisory Board should be for the Public Health Service, not alone for the Hygienic Laboratory, and that they should have meetings at certain stated periods of the year; Add to the Board the Chief of the Bureau of Chemistry, who admin- isters the Pure Food and Drug Laws; Strike out the ten-day limitation in any one year for their services; Change the compensation for the Advisory Board of ten dollars per day to an honorarium that would entitle the Government to consult them in person or by letter whenever necessary ; Provide a School of Instruction for Health Officials of the country, after the pattern of the School of Instruction upon Roads provided by the Department of Agriculture. The faculty of teachers could be secured from the experts of the Government Services; Provide an additional Assistant Secretary skilled in Public Health Matters. This recommendation has had the endorsement of many prom- inent members of the American Medical Association and the Committee of One Hundred. At the hearings before the Interstate and Foreign Commerce Com- mittee of the House of Representatives on Bills relating to the Health Activities of the General Government, Miss Mabel Boardman, of Wash- ington, D. C., member of the Sub-committee on Legislation of the Committee of One Hundred, said: fall thought it was unfortunate that when the Department of Agriculture was formed it should not have had a much broader scope; that it should have been a department of national resources, and that under seuch a department the human resources would have the most prominent importance, because it would be for the benefit of the human resources of the country that all other recources were of value; that in such a department there should be a bureau of public health. * * *’— (Pages 126 et seq., part II of the Hearings held June 3d, 1911.) I heartily endorse her idea that the Bureau of Public Health should be an integral part of the Department of Agriculture. This Department is now in close touch with the authorities in many of the States and Colonies of the country, through its Inspection Services, Experiment Stations and Laboratories located therein. Much of the work is related to the Public Health. It would be a wise move to transfer the Bureau, preserving its autonomy in toto, to the Department of Agriculture, and to appoint an Assistant Secretary, skilled in Sanitary Science,-to codperate with the » Surgeon-General of the Public Health Service. A minor part of the duties of the Bureau of Public Health are connected with the Treasury Department, hence there is no cogent reason for continuing it in that Department. Sanitation is not alluring to the officials of this Department. There have been five Assistant Secretaries of the Treasury, in the last four years, who have had supervision of the Bureau of Public Health. 27 IMPORTANCE OF CLEAN AND COLD MILK. CLEAN MILK can easily be secured by the exercise of care. The meth- ods should be now known by everyone. ‘The importance of using the hooded milk pail cannot be too forcibly urged. W. A. Stocking, Jr., made tests in a stable where but little care was given to cleanliness. Under the same conditions he found the milk drawn in the open pail contained 10,317,600 bacteria to the teaspoonful, whilst that drawn in 3 : — ~ —=<