V66 
 
Cornell University Library 
 QR 121.F85 
 
 [Miscellaneous reprints on mill<; Pasteur! 
 
 3 1924 003 234 063 
 
LOW TEMPERATURE PASTEURIZATION 
 OF MILK AT ABOUT 68° C. (155° F.). 
 
 By ROWLAND GODFREY FREEMAN, M.D., 
 
 Pathologist to the Foundling Hospital ; Pathologist to St. Mary's Free 
 Hospital for Children, New York. 
 
 Reprinted from the Archives ok Pediatrics, August, 1896. 
 
Cornell University 
 Library 
 
 The original of tiiis book is in 
 tine Cornell University Library. 
 
 There are no known copyright restrictions in 
 the United States on the use of the text. 
 
 http://www.archive.org/details/cu31924003234063 
 
LOW TEMPERATURE PASTEURIZATION OF MILK AT 
 ABOUT 68° C. (155° F.).* 
 
 BY ROWLAND GODFREY FREEMAN, M.D., 
 
 Pathologist to the Foundling Hospital; Pathologist to St. Mary's Free 
 Hospital for Children, New York. 
 
 During the winter of 1891-92, stimulated by the thorough 
 work of Bitter,' I made a study of the subject of pasteurization 
 of milk. My conclusions at the time were'' that pasteurization 
 of milk at 75°C. (i67°F.) was superior to other methods of 
 sterilizing, and as there was no apparatus obtainable by which 
 milk could be definitely pasteurized at that temperature, 1 set 
 myself the task of devising one. The result exceeded my expect- 
 ation, for I was able to contrive a simple apparatus which produced 
 a sufficiently definite temperature without the aid of a thermome- 
 ter. The use of a thermometer in sterilizing milk gives good 
 results only when very carefully watched. It is moreover very 
 difficult even when watching a thermometer to bring a fluid to 
 any fixed temperature and hold it at that temperature for half an 
 hour. The apparatus is based on the fact that if two fluids at 
 different temperatures are placed in contact these two tempera- 
 tures will be equalized. I found that by immersing in a definite 
 amount of boiling water, the source oi heat having been 
 removed, a properly proportioned amount of cold milk intro- 
 duced in bottles under such conditions that they will not break, 
 I was able to raise the milk to about the desired temperature, 
 i.e., 75°C. (i67°F.). The amount of boiling water used in the 
 apparatus was such that, in raising the temperature of the 
 milk through about 60'^C. (io8°F.) the water itself lost an 
 equivalent amount of heat so that when the milk reached the 
 maximum temperature the water was of the same temperature. 
 
 It seemed to me wise at that time to arrange the appa- 
 ratus for 75°C. because 
 
 a. The injurious chemical changes caused by heating milk 
 are said to begin at So'C. 
 
 b. Milk heated to 75''C. for 20 minutes is fairly sterile. 
 Milk which before pasteurization contains a hundred thousand 
 or more living germs in each cubic centimeter as a rule after 
 pasteurization shows no growth on a Petri plate in three days. 
 
 * Read before the American Pediatric Society, Montreal, May 26, 1896. 
 
V 
 
 2 Freeman : Pasteurisation of Milk. 
 
 c. This temperature is sufficient to destroy the pathogenic 
 germs which are most feared in milk including the bacillus tuber- 
 culosis, bacillus typhosis, and the bacillus diphtheriae. 
 
 1 felt convinced at that time that 75°C. was as high as milk 
 should be sterilized and 1 was' inclined to think that a lower 
 temperature would be as safe were it not for the high temperature 
 at which the thermal death point of the bacillus tuberculosis was 
 at that time placed by those who had experimented to determine 
 'it. From one point of view there is decided advantage in pasteur- 
 izing milk below 7o^C., for at about 70^C. the change in the taste 
 of milk takes place, while milk heated to a lesser degree retains 
 its original flavor unchanged. This change in the taste of milk 
 caused by cooking, while it passes unnoticed by infants brought 
 up on sterilized milk is often strongly objected to by older children 
 and adults, so that in the practice of medicine we are frequently 
 forced to a choice between raw milk or no milk at all. 
 
 If, then, milk can be satisfactorily pasteurized below 70°C. we 
 have gained a distinct advantage in the taste of the milk and also 
 avoid to a greater degree the chemical changes caused in the milk 
 by heat. 
 
 Pasteurization at 68°C. as far as the ordinary air bacteria 
 found in milk are concerned, gives almost as good result as 
 pasteurization at 75°C. Usually a Petri plate of nutrient gelatine 
 planted with pasteurized milk shows no growth for several days, 
 while the same milk before pasteurization shows an extensive 
 growth in 24 hours. The ordinary effect of the low temperature 
 pasteurization is well shown by the accompanying photograph 
 (Fig. i). At the end of a week or ten days I find often a growth 
 of only a single organism. This milk then is not absolutely 
 sterile, but for that matter milk boiled at ioo°C. (2i2°F.) a single 
 time is not sterile. 
 
 The milk is, however, freed from almost all the living germs, 
 and moreover those pathogenic bacteria which we know to be 
 most likely to cause disease through their presence in milk are 
 also destroyed. It will be seen that the only pathogenic bacte- 
 rium in the accompanying table which is notdestroyed by a short 
 exposure to a temperature of 6o''C. or less is the bacillus 
 tuberculosis. There is evidence here that this micro-organism 
 is destroyed by a temperature of less than 70°C. and indeed by a 
 temperature of 6o°C. of sufficient duration. These reports are 
 the most recent on the thermal death point of the bacillus 
 
Hreeman : Pasteurisation of Milk. 
 
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4 Freeman : Pasteuri:{^ation of Milk. 
 
 tuberculosis that I have found. I will refer to these more 
 particularly to show how thorough the work was which led to 
 these conclusions. 
 
 Table of the Thermal Death-point, in a Moist Medium, of Certain 
 Pathogenic Bacteria. 
 
 SPECIES. 
 
 EXPOSURES. 
 
 OBSERVER, 
 
 Spirillum cholerae 
 
 60° C. for ten minutes. 
 
 Kitasato' 
 
 Asiaticae. 
 
 59" C. for one minute. 
 
 Van Geuns* 
 
 
 54" C. for five minutes. 
 
 u 
 
 
 52° C. for four minutes. 
 
 Sternberg^ 
 
 Streptococcus pyogenes. 
 Bacillus typhosis. 
 
 52° C. for ten minutes. 
 60° C. for five minutes. 
 
 Sternberg" 
 Buchner' 
 
 
 60° C. for one minute. 
 
 Van Geuns^ 
 
 
 '57° C. for five minutes. 
 56° C. for ten minutes. 
 56° C. for five minutes. 
 
 Janowski' 
 Sternberg'" 
 Van Geuns" 
 
 Bacillus diphtherise. 
 
 58° C. for ten minutes. 
 
 Welch & Abbott'-' 
 
 Staphylococcus pyogenes 
 
 56° C.-58° C. for ten minutes. 
 
 Sternberg'3 
 
 aureus. 
 
 
 
 Bacillus coli communis. 
 
 60° C. for ten minutes. 
 
 Weisser" 
 
 Pneumococcus. 
 
 56° C. 
 
 60° C. for one minute. 
 
 Sternberg's 
 Van Geuns'6 
 
 Bacillus tuberculosis. 
 
 70° C. for. one minute. 
 
 Crancher and Li- 
 doux-Libard" 
 
 
 70° C. for ten minutes. 
 
 Yersinia 
 
 
 68° 0.-68^" C. for twenty 
 minutes. 
 
 Bitter" 
 
 
 65" C. for fifteen minutes. 
 
 Forster'" 
 
 
 60° C. for twenty minutes. 
 
 Bonhoff" 
 
 
 60° .C. for fifteen minutes. 
 
 Schroeder='^ 
 
 In considering these data concerning the thermal death point 
 of the bacillus tuberculosis it may be well first to point out 
 certain reasons for variations in the results of different series of 
 experiments. 
 
 a. Certain of the experiments were done with sputum, the 
 thick masses of which are penetrated by heat more slowly than 
 liquids. 
 
 b. Varying virulence in the bacteria used for inoculation. 
 
 c. In some, bovine tubercle bacilli were used while in 
 others human. 
 
 d. The test of life of tubercle bacilli. 
 
 The bacillus tuberculosis is difficult to grow on culture media 
 and its growth is, moreover, very slow. On this account in most 
 of the experiments to determine the thermal death point of the 
 organism, the test of life of the bacillus has been applied, not by 
 planting in nutrient media, but by inoculation into susceptible 
 
Freeman : Pasteuriiation of Milk. 5 
 
 animals, preferably guinea-pigs. Such inoculations may be Inade 
 either hypodermically, in the ear vein, or into the peritoneal 
 cavity. At the time of the earlier experiments little was known 
 of the lesions produced by dead tubercle bacilli. It has recently 
 been shown by Prof. Prudden" that the injection of tubercle bacilli 
 killed by repeated boiling and undoubtedly dead is followed by 
 the production of lesions closely resembling some of the lesions 
 caused by the introduction of living tubercle bacilli. After such 
 injection an examination of the organs showed circumscribed 
 collections of epithelioid cells and giant cells. In this tissue 
 tubercle bacilli were found. These lesions were apparently due 
 merely to the mechanical irritation of the dead tubercle bacilli 
 and there was no indication that any general progressive dis- 
 ease was set up. This work is of great importance in connec- 
 tion with the determination of the thermal death point of the 
 bacillus tuberculosis for in every such experiment either living 
 or dead tubercle bacilli are injected, so that any observer not 
 familiar with the action of dead tubercle bacilli might pronounce 
 an animal tuberculous that was suffering only from the me- 
 chanical irritation of dead tubercle bacilli and as a result would 
 set the thermal death point of the tubercle bacillus higher than it 
 should be. 
 
 Yersin,"* working in the Pasteur Institute in 1888, in a series 
 of experiments with an old culture of tubercle bacilli found that 
 he could get a growth after an exposure of ten minutes to a 
 temperature of 6o°C. but that after an exposure of the same 
 duration to 70°C. no growth was obtained. These experiments 
 were repeated a number of times with the same result. 
 
 Bitter," of the Hygienic Institute of Breslau, in an article 
 published in 1890, states that 68''-68.5''C. for 20 minutes will 
 destroy the bacillus tuberculosis. These results were obtained 
 by inoculation experiments with guinea-pigs. 
 
 Prof. Forster," of the Hygienic Institute, at Amsterdam, 
 published in October, 1892, the result of a long series of experi- 
 ments to determine the thermal death point of the bacillus 
 tuberculosis. He used inoculation experiments in guinea-pigs 
 with various materials including a milky substance squeezed from 
 tuberculous tissue of the udder, also tuberculous tissue from the 
 pleura and sputum containing the tubercle bacillus. He thus 
 made use of both the human and bovine tubercle bacillus. He 
 
6 Freeman : Pasteurisation of Milk. 
 
 found that they were killed by 55°C. for 6 hours, by 6o°C. for 
 one hour, but were not killed by 6o°C. for 45 minutes. 
 
 This article was followed two months later by one by Dr. 
 Bonhoff," an assistant of the Hygienic Institute at Berlin, giving 
 the results of experiments extending over the past six months. 
 He used a culture of the bacillus tuberculosis and injected guinea- 
 pigs. He says "from these results 1 conclude that about a 
 temperature of 6o°C for 20 minutes is ample to kill tubercle 
 bacilli in pure culture, or at least to render them harmless to 
 the animal organism." This publication of Dr. Bonhoff places 
 the thermal death point lower than any previous observation. 
 
 A year later Prof Forster'" published the result of another 
 series of experiments in his laboratory, done by C. de Man,^' to 
 determine more accurately the time necessary to destroy the 
 organism at different temperatures. The data of this second 
 paper correspond fairly with that of the first, but are fuller. He 
 finds that the following exposures will kill the bacillus tuber- 
 culosis : 
 
 55° C. for four hours. 
 
 60° C. for one hour. 
 
 65° C. for fifteen minutes. 
 
 70° C. for ten minutes. 
 
 80° C. for five minutes. 
 
 90° C. for two minutes. 
 
 95° C. for one minute. 
 Schroeder's" figure is of itself not of much value since it 
 was the result of only one experiment, but taken with the other 
 evidence presented is confirmatory. Schroeder undertook to 
 ascertain by the inoculation of guinea-pigs the extent of the oc- 
 currence of the bacillus tuberculosis in the milk supply of Wash- 
 ington. He proposed to subject the milk before injection to a 
 temperature of 60° C. for fifteen minutes to destroy other bac- 
 teria which might interfere with his results, supposing that such 
 temperature was not sufficient to kill the bacillus tuberculosis. 
 To make sure that such exposure would not injure the bacillus 
 tuberculosis, he planted milk from a culture of the bacillus tuber- 
 culosis, and then used a temperature of 60° C. for fifteen minutes. 
 The animal injected with the milk was killed on the fifty- 
 eighth day and showed no evidence of tuberculosis, although 
 two other animals subjected to the same treatment without the 
 heating died on the twenty-fifth and twenty-eighth days. 
 
Freeman : Pasteurisation of Milk. 
 
 The evidence of these observers seems to me sufficient for a 
 conclusion that a temperature of 65° C. for fifteen minutes is suf- 
 ficient to kill tubercle bacilli. We have, so far as 1 know, no 
 equally recent work the results of which are opposed to this 
 conclusion. Having been thus persuaded that the only obstacle 
 to the pasteurization of milk below 70° C. has been removed, 1 
 have modified the pasteurizer in order to fit it for the desired 
 temperature. In so doing 1 have been able to do away with a 
 source of error in the old apparatus, and so far as 1 know in all 
 sterilizers, that is, a marked difference of temperature between 
 the milk in the bottom and that in the top of the bottle. By 
 elevating the receptacle so that only the lower portion is in con- 
 tact with the hot water this equalization of temperature through- 
 
 no. 3. — Showing the apparatus arranged 
 
 for heating the milli before the pail is 
 
 covered. 
 
 FIG 4. — Showing the apj-aratus 
 arranged for cooling the 
 milk. 
 
 out the bottle is obtained. This apparatus is so arranged that a 
 temperature of more than 6<y" C. and less than 70° C. may be 
 maintained for half an hour. 
 
 If the milk introduced has a temperature of lo^' C. (50° F.) the 
 resultant temperature will be about 68° C. (155° F.); while if the 
 milk has a temperature of 20° C. (68° F.), the resultant tempera- 
 ture will be about 69^^° C. (157° F.). Milk from a good refrig- 
 erator has usually a temperature of about 15° C. (59° F.). 
 
 The apparatus (Fig. 3) consists of two parts, a pail for the 
 water and a receptacle for the bottles of milk. The pail is a 
 simple pail with a cover; there is a groove extending around the 
 pail to indicate the level to which it is to be filled with water, 
 and supports inside for the receptacle for the bottles of milk to 
 
8 Freeman : Pasteuriiatton of Milk. 
 
 rest on. The receptacle for the bottles of milk consists of a 
 series of hollow zinc cylinders fastened together; this fits into 
 the pail so that the lower inch of the cylinders is immersed in 
 the water. This receptacle has two sets of horizontal supports, 
 the upper set continuous around the receptacle for use while the 
 milk is being heated; the lower interrupted .set is used for 
 raising the receptacle during cooling. Such receptacles are 
 made for ten 6-oz. bottles, seven 8-oz. bottles, three i-pint and 
 one >^-pint bottles and two quart bottles. There is also a large 
 apparatus for the use of hospitals or public institutions which has 
 a recepta.cle for forty-three 6-oz. or 8-oz. bottles. 
 
 The apparatus is used in the following way: The pail is 
 filled to the level of the groove with water, covered and put on 
 the stove, the receptacle for the bottles being left out. The 
 bottles of milk are then filled, stoppered with cotton and dropped 
 into their places in the cylinders. Sufficient water is poured into 
 each cylinder to surround the body of the bottle. As soon as 
 the water in the pail boils thoroughly it is taken from the stove 
 and set on a mat or table or other non-conductor in a place 
 where there is not a draft of wind blowing on it. The lid of the 
 pail is removed and the receptacle for the bottles of milk is put 
 in the pail so that the receptacle rests on the upper continuous 
 supports. The lid is then rapidly put on the pail and the pail is 
 thus allowed to stand for three-quarters of an hour. During the 
 first fifteen minutes the temperature of the milk rises — as may be 
 seen by the accompanying chart — to about its maximum or 
 above 65° C, the point desired for pasteurizing, and remains 
 there the remaining thirty minutes. During the last fifteen 
 minutes it falls about one degree; at the end of forty-five 
 minutes the cover of the pail is removed, the receptacle is lifted 
 and given a turn so as to rest on the upper supports (Fig. 4), 
 thus bringing the top of the cylinders containing the bottles 
 above the level of the paiL The pail is then put under a cold 
 water faucet and the water is allowed to run into the pail 
 and overflow, but it should not run into the cylinders. Thus 
 the hot water is replaced by cold water, and in fifteen minutes 
 the milk in the bottles is of about the temperature of the cold 
 water used. The bottles may then be put into a refrigerator 
 until required for feeding. This rapid cooling is a most impor- 
 tant part of a low temperature sterilization, the importance of 
 which is apt to be overlooked. 
 
Freeman : Pastenriiation of Milk. 9 
 
 Certain points in this chart to which I wish to call special 
 attention are: 
 
 I. The apparent laci< of precision in the action of the appa- 
 ratus, due to the unknown temperature of the milk introduced, 
 is to a considerable extent corrected. The amount and tempera- 
 
 S- 10 fS' XO iiT 30 SiT >^o "-T So (TiT 6( 
 
 (,<-?C 
 60' C 
 
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 CHART SHOWING TWO OBSERVATIONS ON THK TLMl'l'.KAl L KE UF MILK DURING 
 PASTEURIZATION IN THE APPARATUS. 
 
 ture of the boiling water used for heating is definite; the amount 
 of cold milk to be heated is definite, but the temperature of the 
 milk is such as may be covered by the word cold or by refrig- 
 erator temperature. The chart shows that the apparatus will 
 correct a considerable variation of the temperature of the milk 
 used by the ability of the boiling water to carry cold milk 
 
10 Freeman: Pasteuriiation of Milk. 
 
 through a greater number of degrees of temperature than warmer 
 milk; on this account whether the milk is introduced at a tem- 
 perature of io° C. (50° F.) or 20° C. (68° F.), the resultant tem- 
 perature varies only 2" C. 
 
 2. The very rapid rise in the temperature of the milk intro- 
 duced. It rises about thirty-five or forty degrees in the first five 
 minutes, about ten degrees in the second five minutes and about 
 five degrees in the third. 
 
 3. The even temperature preserved after the rise; a varia- 
 tion of not more than a degree during the last twenty-five 
 minutes. 
 
 4. The rapid fall of the temperature in a cold water bath; a 
 fall of about thirty-five degrees in the first five minutes. This 
 cooling in a cold water bath takes place eight times as fast as in 
 
 a refrigerator. 
 
 Summary. 
 
 Pasteurization at between 65° C. (149° F.) and 70° C. (167° F.) 
 is recommended for the following reasons: 
 
 1. It destfoys almost all the ordinary air bacteria which occur 
 commonly in milk. 
 
 2. It destroys the bacillus tuberculosis, the bacillus typhosis, 
 the bacillus diphtheria and many other pathogenic bacteria. 
 
 3. It causes no change in the taste of the milk and avoids 
 those chemical changes in milk which are produced by higher 
 temperatures. 
 
 4. It is possible to pasteurize accurately at this temperature 
 without the use of a thermometer. 
 
 References. 
 
 1. Bitter. Zeitschrift fur Hygiene, 1890. Bd. VIII. S. 240. 
 
 2. Freeman. Medical Record, 1892, July 2d. 
 
 3. Kitasato. Zeitschrift fur Hygiene, 1888. Bd. V. S. 134. 
 
 4. Van Geuns. Archiv. fur Hygiene, 1889. Bd. IX. S. 369. 
 
 5. Sternberg. Manual of Bacteriology. P. 504. 
 
 6. Sternberg. Ibid. P. 276. 
 
 7. Buchner. Centralblatt fur Bacteriologie, etc., 1888. Bd. 
 
 IV. P- 386. 
 
 8. Van Geuns. Ibid. 
 
 9. Janowski. Centralblatt fur Bacteriologie, etc., 1890. Bd. 
 
 VIII. S. 417. 
 
 10. Sternberg. Ibid. P. 351. 
 
 1 1. Van Geuns. Ibid. 
 
 12. Welsh and Abbott. Bui. of Johns Hopkins Hospital, 
 
 1891, Vol. II. P, 25. 
 
Freeman : Pasteuriiation of Milk. 1 1 
 
 13. Sternberg. Ibid. P. 267. 
 
 14. Weisser quoted by Sternberg. Ibid. P. 442. 
 
 15. Sternberg. Ibid. P. 297. 
 
 16. Van Geuns. Ibid. 
 
 17. Grancher and Lidoux-Libard. Archiv. de Med. Expr., 
 
 etc., 1892. IV. I. 
 
 18. Yersin. Annales de Inst. Pasteur. I. 2. P. 64. 
 
 19. Bitter. Ibid. 
 
 20. Forster. Hygienische Rundschau, 1893. No. 15. 
 
 21. BonhofF. Hygienische Rundschau, 1892. No. 2}. 
 
 22. Schroeder. Bui. of U. S. Bureau of Animal Industry. 
 
 No. 7. P. 75. 
 
 23. Prudden and Hodenpyl. N. Y. JVledical Journal, 1891, 
 
 June 6 and 20. 
 
 24. Yersin. Ibid. 
 
 25. Bitter. Ibid. 
 
 26. Forster. Hygienische Rundschau, 1892, Oct. 15. S. 869. 
 
 27. Bonhoff. Ibid. 
 
 28. Forster. Hygienische Rundschau, 1893. No. 15. 
 
 29. C. de Man. Archiv. fur Hygiene. Bd. XVIII. 2 Heft. 
 
 203 West Fifty-seventh Street. 
 
 DISCUSSION. 
 
 Dr. T. M. Rotch. — These experiments of Dr. Freeman's are 
 very important and practical. I hope that he will also show us 
 how to heat a single bottle when it is to be heated to 99° or 
 100° F. I suppose it could be done in the same way. As to 
 the experiments which Dr. Freeman reports, I have had some- 
 thing of the same kind done in Boston with very similar results. 
 
 Dr. L. Emmett Holt. — 1 have used Dr. Freeman's apparatus 
 for years with the higher temperature (167° F.), and have found 
 it most satisfactory, it is so simple that any mother or nurse 
 can use it. The chances of error are very small if the directions 
 are followed. The importance of rapid cooling is often forgotten. 
 Although nurses are told, they will not do it unless the point is 
 emphasized. 
 
 Dr. J. P. Crozer Griffith. — I believe, even without personal 
 experience with it, that Dr. Freeman's pasteurizer is one of the 
 most useful appliances we can have in the preparation of food 
 for infants. I have seen it before but have never used it, although 
 I shall certainly do so in future. It is not as widely known in 
 Philadelphia as it deserves to be — in fact, is very httle known 
 there. 
 
 I have experimented with pasteurizing with an ordinary 
 sterilizer, leaving the cover off to a greater or less extent, and 
 using a thermometer in the milk to determine how accurate the 
 results were. In this way a fair result can be obtained if the 
 
1 2 Freeman : Tasteuri'iation of Milk. 
 
 process is carefully watched. The trouble is, however, that the 
 heat of the stove, and the consequent temperature of the milk, 
 is sure to vary at different times, and that accuracy is impossible 
 even with the strictest attention. 
 
 Dr. Freeman's pasteurizer obviates all those difficulties, and is 
 besides so simple in its application that 1 have only words of 
 praise for it. 
 
 Dr. Freeman. — Dr. Rotch's suggestion to apply the same 
 principle used in the pasteurizer to the heating of a single bottle 
 to the proper temperature for feeding, 1 will try to carry out. It 
 would seem an easy matter to adjust such a bottle-warmer so 
 that it would produce an accurate temperature. 
 
 A question has been raised as to the advisability of the term 
 pasteurize. It seems to me that this name is necessary, as no 
 other word indicates the same thing — ^that is a low temperature 
 sterilization followed by rapid cooling. The rapid cooling is a 
 most important part of the process. If we use the expression 
 low temperature sterilization, the rapid cooling is apt to be over- 
 looked. 
 
 IVlilk, should be used only during the twenty-four hours fol- 
 lowing pasteurization. Although the pasteurized milk will not 
 sour in several days if kept cold, it should be used only during 
 the interval 1 have indicated. Bottles of milk pasteurized at 
 about 68° C. and left standing on my laboratory table during the 
 spring usually showed no separation of casein in less than three 
 days. IVlilk pasteurized at 75° C. 1 have found to keep for a 
 week or ten days in a refrigerator. A very good demonstration 
 of the keeping qualities of pasteurized milk has been afforded by 
 the Nathan Straus Milk Depots of New York. The milk sold at 
 these depots is pasteurized at about 75° C. in large apparatuses 
 constructed on the same principle as the one 1 have just shown. 
 After cooling it is stored in iced water until dispensed. As many 
 as seven thousand bottles are distributed by these depots during 
 some days in summer. This milk supplies the very poor of 
 New York, and goes into many homes that are not supplied 
 with ice. Two years ago, while preparing a paper I inquired 
 of the superintendent whether they were at all troubled by any 
 of the milk souring in the tenement houses. He replied that 
 they had had one complaint, which he had investigated, and had 
 found that the milk had been kept under the kitchen stove. 
 When this charity was started in 1893 I advised pasteurization 
 at 75° C, and it was undertaken, although the gentleman having 
 charge of it was assured by others that milk pasteurized at this 
 temperature would not keep under the conditions existing in 
 tenement houses, and that a temperature of at least 80° C. or 
 ^0° C. should be used. They have seen no necessity for using 
 a higher temperature after three years' experience. 
 
ARCHIVES 
 
 REDIATf{M 
 
 A Monthly Journal Devoted to Diseases of 
 Infants and Children. 
 
 Edited by 
 
 FLOYD M. CRANDALL, M.D. 
 
 " Pediatrics is tiie specialty of the 
 general practitioner." 
 
 Volume begins with January. Sub- 
 scriptions may begin at any time. 
 $3.00 a year in advance. 
 
 E. B. TREAT, - Publisher, 
 
 5 Cooper Union, New York. 
 
PASTEURIZED MILK 
 
 AS SUPPLIED TO THE POOR 
 
 BY THE 
 
 Straus Milk Depot of New York 
 
 BY 
 
 ROWLAND GODFREY FREEMAN, M.D. 
 
 PATHOLOGIST TO THE FOUNDLING HOSPITAL; PATHOLOGIST TO ST. MAKy's 
 HOSPITAL FOR CHILDREN ; ASSISTANT PHYSICIAN TO ROOSEVELT 
 HOSPITAL, OUT-PATIENT DEPARTMENT 
 
 Reprinted from the Medical Rbcord, August 4, 1894 
 
 NEW YORK 
 
 TROW DIRECTORY, PRINTING AND BOOKBINDING CO. 
 
 201-213 East Twelfth Street 
 
 1894 
 
PASTEURIZED MILK 
 
 AS SUPPLIED TO THE POOR 
 
 BY THE 
 
 Straus Milk Depot of New York 
 
 BY 
 
 ROWLAND GODFREY FREEMAN, M.D. 
 
 PATHOLOGIST TO THE FOUNDLING HOSPITAL; PATHOLOGIST TO ST. MARY's FKEE 
 
 HOSPITAL FOR CHILDREN ; ASSISTANT PHYSICIAN TO ROOSEVELT 
 
 HOSPITAL, OUT-PATIENT DEPARTMENT 
 
 Reprinted from the Mbdical Record, August 4, 1894 
 
 NEW YORK 
 
 TROW DIRECTORY, PRINTING AND BOOKBINDING CO. 
 
 201-213 East Twelfth Street 
 
 1894 
 
PASTEURIZED MILK AS SUPPLIED TO 
 THE POOR BY THE STRAUS MILK DE- 
 POT OF NEW YORK/ 
 
 It is the purpose of the writer to describe some of the 
 details of a most worthy charity, the expenses of which 
 have been met by one man, since perhaps other equally 
 charitable persons here or in other parts may be disposed 
 to carry out the same sort of work, and may thus be able 
 to benefit by the methods here described. 
 
 Since there can be no doubt that the milk supply may 
 be a source of danger on account of the large number, 
 and possible pathogenic character, of the micro-organisms 
 contained in it, it becomes of the greatest importance to 
 investigate the manner of this contamination and the 
 methods of avoiding its dangers. The most important 
 source of contamination is undoubtedly the dairy, where 
 dirty and ignorant methods are almost universally em- 
 ployed, not only during the milking but in the subse- 
 quent care of the milk. Delay in transportation affords 
 time for the multiplication of the germs which have en- 
 tered the milk. 
 
 It is evident that this danger may be met in one of 
 two ways : best by a reformation in dairy methods and 
 the manner of transportation, but failing in this, by sterili- 
 zation. It is the object of this paper to show how this 
 latter has been accomplished on a large scale in New 
 York, for the purpose of supplying milk to the poor. 
 
 As such an undertaking is original and certainly worthy 
 of emulation, and at the same time of great service to 
 those members of the profession who practise among the 
 poor, it may be of interest to know how the work was 
 done and what the results were. 
 
 This enterprise is due to the philanthropy of Mr. Na- 
 
 > Read before the Section of Pediatrics of the New York Academy 
 of Medicine on May lo, 1894. 
 
than Straus, who, in the spring of 1893, established and 
 has since maintained a depot for supplying the poor with 
 a good quality of raw and sterilized milk. His first aim 
 was to obtain as pure a milk supply as possible, and for 
 this purpose the dairy was inspected by Mr. S. K. John- 
 son, veterinarian of the New York Board of Health, and 
 was approved by him. The depot in New York has been 
 admirably planned and superintended by Mr. A. L. Kin- 
 kead. Three sorts of milk were provided : pasteurized 
 ordinary milk, pasteurized modified milk, and raw milk. 
 
 Pasteurization at about 75" C. (167" F.) was used in- 
 stead of sterilization at 100° C. (212° F.), under the as- 
 sumption that it furnishes a more nutritious and more 
 digestible milk than that sterilized at a higher tempera- 
 ture, and at the same time one which is freed from dele- 
 terious germs. Pasteurized ordinary milk was sold in 
 eight-ounce bottles at one and a half cent each. 
 
 The pasteurized modified milk is simply a one-half 
 dilution of ordinary milk with the addition or sufficient 
 sugar of milk to bring up the amount in the dilution to 
 five per cent., and enough lime-water to neutralize any 
 slight acidity the milk might have, and then the mixture 
 is pasteurized. 
 
 In this way a milk approximating somewhat mothers' 
 milk is furnished. The formula used is : 
 
 Sugar of milk 1 2 oz. 
 
 Lime-water 8 oz. 
 
 Milk I gal. 
 
 Water 1 gal. 
 
 It is evident that the deficiency in this dilution is in 
 fat. It was intended, however, for very young or sick 
 infants, and for these answered very well. On the other 
 hand, to have increased the fats would have introduced 
 some difficulties. This pasteurized modified milk is dis- 
 pensed in six- ounce bottles, a charge of ij^ cent being 
 made for each bottle. With each six or eight-ounce bot- 
 tle of milk a sterile nipple is supplied. A deposit is re- 
 quired of 2j4 cents for each six- ounce bottle and nipple, 
 and 3 cents for each eight-ounce bottle and nipple. 
 It was thus intended to furnish for infants and sick 
 
5 
 
 children a sterile milk of good quality in a sterile nursing- 
 bottle, with a sterile nipple through which it could be 
 fed. 
 
 This milk depot was located on a pier at the foot of 
 East Third Street, that situation being accessible to a 
 very large tenement-house population. Awnings and 
 seats were put up on the pier so that the babies and their 
 mothers could remain there and inhale the fresh air from 
 the river. 
 
 The building which was erected was, owing to the 
 character of the site, of necessity long and narrow ; it 
 was placed several feet from the edge of the pier, so that 
 an outside passageway connecting the rooms was re- 
 served. The building was divided into four rooms. The 
 first room is used for sterilizing the bottles, stoppers, and 
 nipples, and preparing and pasteurizing the milk. The 
 second room is occupied by large water-baths of iced 
 water for keeping the pasteurized milk until it is deliv- 
 ered. The third room contains iceboxes for the cans of 
 raw milk. The fourth room, which is nearest the end of 
 the pier, is devoted to the business of selling the milk. 
 
 The first of these rooms contains all the apparatus : the 
 ovens for sterilizing the bottles at a dry heat of 150° C. 
 (302° F.), the mixer used for the preparation of the 
 modified milk, the pasteurizers, and the trough of run- 
 ning water for rapid cooling after pasteurization. This 
 room has a slanting cement floor which can be flushed 
 with a hose for purposes of cleanliness. The ovens for 
 sterilizing the bottles are made of sheet iron and heated 
 by gas. The bottles, after being thoroughly cleansed, 
 are placed in this oven, which is then closed and the gas 
 beneath is lighted. The bottles are kept here at a tem- 
 perature of 150° C. (302° F.) for one hour. The bot- 
 tles used were especially designed and made for the pur- 
 pose. They have sloping necks so as to be easy to clean, 
 and spheroidal bottoms so that they will not stand up. 
 This latter peculiarity was introduced so that they might 
 not be opened and left standing uncorked, thus allow- 
 ing a further contamination of the milk by bacteria. 
 
 The method of pasteurization used is the same as that 
 applied by me to the small apparatus which I described 
 
two years ago.' The principle is as follows: If into a 
 definite amount of boiling water, the source of heat hav- 
 ing been removed, a properly proportioned amount of 
 cold milk be introduced in bottles under such conditions 
 that they will not break, the temperature of the milk 
 will be raised to the desired point, i.e., 75° C. (167° F ). 
 The amount of boiling water used in this apparatus is 
 such that, in raising the temperature of the milk through 
 about 60° C. (108° F.) it itself loses an equivalent 
 amount of heat, so that when the milk reaches its maxi- 
 mum temperature the water is of the same temperature. 
 
 The apparatus used at the Straus depot consists of 
 large copper boilers for the water, and copper receptacles 
 
 The Pasteurizing Apparatus arransed for Heating the Milk 
 before the Pail is Covered. 
 
 for the bottles of milk. The boilers are twenty- four 
 inches long and have a groove encircling them, to indi- 
 cate the point to which they are to be filled with water. 
 The receptacles consist of groups of copper cylinders, 
 each one just large enough to contain one bottle. These 
 receptacles are made of different sizes for six-ounce, 
 eight-ounce, or pint bottles. The apparatus is thus 
 
 ' On the Sterilization of Milk at Low Temperature, etc. Mbdical 
 Record, July 2, 1892. 
 
essentially the same as the small apparatus referred to 
 above, except that it is of larger size, allowing a greater 
 number of bottles to be pasteurized at a time. 
 
 The method of pasteurizing the milk is as follows : 
 The boilers are first filled with water to the groove and 
 the gas stoves beneath them are lighted. The sterilized 
 bottles, having been cooled, are now filled with milk and 
 loosely stoppered with rubber corks which have previ- 
 ously been sterilized in boiling water. The stoppered 
 bottles are then placed in the hollow copper cylinders of 
 the receptacles, and the space surrounding the body of 
 the bottle in each cylinder is filled with cold water. As 
 they are prepared, they are left on a shelf until the water 
 in the boilers generates steam vigorously, indicating a 
 temperature of ioo° C. (212° F.). The gas under the 
 boilers is then turned off, and the receptacles containing 
 the filled bottles are set in the boiling water ; the boilers 
 are then covered and not disturbed for half an hour. 
 The milk here reaches a temperature of about 75" C. 
 (167° F.) in ten minutes, and remains at that tempera- 
 ture for the remaining twenty minutes. The receptacles 
 containing the bottles are then removed and placed in 
 the tank of running water for twenty minutes, at the end 
 of which period the milk in the bottles has reached 
 nearly the temperature of the surrounding water, that is, 
 2o°-25" C. (68°-77° F.). They are then carried into 
 the next room, where the bottles are removed and placed 
 in racks in iced water at a temperature of about 10° C. 
 (50° F.). They are kept here until dispensed. Suffi- 
 cient milk for one day's use is pasteurized, and it is never 
 carried over. 
 
 As soon as one lot of receptacles is taken from a boiler, 
 the gas beneath is lighted, and the temperature of the 
 contained water, now about 75" C. (167° F.), is brought 
 to boiling for a new lot of receptacles, which, with their 
 bottles, are at once introduced. 
 
 A large number of experiments with milk subjected to 
 this treatment, show that by it the practical purposes of 
 sterilization are accomplished. With each bottle of milk 
 a rubber nipple is supplied which has been sterilized in 
 boiling water. 
 
8 
 
 Of this pasteurized milk twenty-five hundred bottles 
 were dispensed in a single week, and thirty-four thousand 
 bottles were supplied during the season. Five persons 
 were employed in this depot during the summer of 1893, 
 including a cashier, a porter, and a scrubwoman. The 
 actual technical work of pasteurizing was accomplished, 
 for the most part, by one man. Many remarkable cases 
 were observed of infants and children with bad surround- 
 ing, and suffering from severe gastro-intestinal disorders, 
 who rapidly improved and attained good health on sim- 
 ply a good sterile food and the fresh air of the pier. It 
 is interesting to note that, although this milk was often 
 kept in hot tenement-houses where ice could not be 
 afforded, only one case of the pasteurized milk turning 
 sour was reported. This case was investigated, and it 
 was found that the milk had been kept under the kitchen 
 stove. 
 
 The scope and technical facilities of this charity will 
 be enlarged this year. Six depots in various parts of the 
 city will be established. The milk will be brought from 
 Delaware County, N. Y., the herd supplying it being 
 first carefully inspected by a veterinarian of the Board of 
 Health. Both raw and sterilized milk will be supplied. 
 The same formula will be used for the modified milk, 
 which will be dispensed in six ounce bottles. Pasteur- 
 ized milk will be sold in eight- ounce and sixteen- ounce 
 bottles. 
 
 In addition to pasteurized ordinary milk and pasteur- 
 ized modified milk, as supplied last year, a pasteurized 
 milk diluted with barley water and sweetened with cane 
 sugar, and containing also table salt, has been introduced 
 at the suggestion of Prof. A. Jacobi. The formula used is : 
 
 Table salt J oz. 
 
 White cane sugar 10 oz. 
 
 Milk 1 gal. 
 
 Barley water I gal. 
 
 This barley milk will be dispensed in six- ounce bottles. 
 This depot will be prepared to supply hospitals and 
 dispensaries. 
 
 205 West Fifty-seventh Street. 
 
Milk as an Agency in the 
 Conveyance of Disease 
 
 BY 
 
 ROWLAND GODFREY FREEMAN, M.D. 
 
 NEW YORK 
 
 PATHOLOGIST TO THE FOUNDLING HOSPITAL ; PATHOLOGIST TO ST. MARY'S 
 
 FREE HOSPITAL FOR CHILDREN ; ASSISTANT PHYSICIAN TO 
 
 ROOSEVELT HOSPITALj OUT-PATIENT 
 
 DEPARTMENT 
 
 Reprint from the Medical Record, March a<y, i8gb 
 
 NEW YORK 
 
 THE PUBLISHERS' PRINTING COMPANY 
 
 132, 134, 136 West Fourteenth Street 
 
 1896 
 
Milk as an Agency in the 
 Conveyance of Disease 
 
 BY 
 
 ROWLAND GODFREY FREEMAN, M.D. 
 
 NEW \ORK 
 
 PATHOLOGIST TO THE FOUNDLING HOSPITAL; PATHOLOGIST TO ST. i\IAkV's 
 
 FREE HOSPITAL FOix' CHILDREN; ASSISTANT PHYSICIAN Ti.' 
 
 ROOSEVELT HOSPITAL, OUT-VATIENT 
 
 DEPARTMENT 
 
 Reprint from the Medical Record, March 2S iSgb 
 
 NEW YORK 
 
 THE PUBLISHERS' PRINTING COMPANY 
 
 132, 134, 136 West Fourteenth Street 
 
 1896 
 
MILK AS AN AGENCY IN THE C(3NVEY- 
 ANCE OF DISEASE. 
 
 During the past twenty-five years a large amount of 
 evidence has accumulated about the causation of dis- 
 ease by milk, and many cases of illness and many 
 epidemics caused by contaminated milk have been re- 
 ported. It has thus seemed desirable to consider, 
 as far as possible in a short paper, the conditions 
 under which milk can become the means for the 
 conveyance of infectious agents; to bring together 
 and tabulate the recent epidemics of disease which 
 have been attributed to milk, and, finally, to draw 
 certain conclusions as to the methods which should 
 be adopted to avoid such disease-producing contam- 
 ination of milk. 
 
 I have collected and tabulated at the end of this 
 article 53 epidemics of typhoid fever attributed to 
 milk, 26 of scarlatina, 11 of diphtheria, 2 of foot-and- 
 mouth disease, 3 of throat affection, 2 of acute poi- 
 soning by milk, and i of cholera asiatica. Only 
 those occurring since 1880 are included, since a tabu- 
 lation up to that date was prepared by Ernest Hart.' 
 
 In inducing these diseases milk has served merely 
 as the vehicle in which the micro-organisms produc- 
 ing the disease have been transported. In order to 
 show clearly how the micro-organisms enter the milk, 
 and why so much disease has been caused by milk, it 
 may be well to look into the milk traffic and the 
 methods employed in expressing the milk from the 
 udder of the cow and the subsequent manipulation 
 and delivery to the consumer. 
 
 Magnitude of the Milk Traffic. — The amount of 
 milk produced, transported, and sold is very large. 
 Great Britain consumes ° two hundred and fifty million 
 gallons a year which costs £17,000,000 or $85,000,000. 
 The United States consumes ' five billion gallons a 
 year. One may gain a more accurate conception of 
 this latter amount by considering that it is nearly equal 
 to the amount of Croton water consumed in New York 
 City in one month. New York City consumes more 
 than seven million gallons a year, an amount that 
 

 Ml , 
 
 ~-T: "C 
 
would more than one-third fill the Bryant Park 
 reservoir. 
 
 The Consumers of Milk — Milk is consumed 
 largely by infants and invalids, for many of whom it 
 is the exclusive article of diet. It is, moreover, usu- 
 ally taken uncooked, either from indifference or on 
 account of the altered taste of cooked milk. This 
 particularly susceptible portion of the community is 
 thus less protected than the robust adult people, who 
 use for the mostpart food that has been more or less 
 sterilized by cooking. The desirability then o£ great 
 care in the handling of milk is evident. 
 
 Sources of Contamination of Milk.— Milk as it 
 exists in the udder of a healthy cow is germ free, 
 that is, it is practically sterile. But in fact milk as 
 it comes to the consumer does contain a large num- 
 ber of living germs. These enter the milk 
 
 s 
 
 in 
 
 dirt, in dust, and in dirty water in various ways, 
 and increase as rapidly as time and temperature 
 allow. It is unfortunate that milk must be drawn 
 from a hair-covered udder on the under surface of 
 a hair-covered cow. This part of the cow's hide 
 retains particles of any dirt on which the cow may 
 lie, as well as dried fa;cal material, especially if 
 the cow has loose evacuations. The droppings of 
 dust and bacteria from the hide of cows during 
 milking, even when the animals are kept fairly 
 clean, are very great. The accompanying illustra- 
 tions (Figs. I, 2, and 3) are a practical demonstra- 
 tion of the extent of this contamination. Three Petri 
 plates, three and one-half inches in diameter, con- 
 taining a layer of sterile nutrient gelatin, were ex- 
 posed for two minutes each on a gentleman's farm 
 near New York. One was exposed out of doors, a 
 second in the barn, and a third under a cow just in 
 front of the milk pail during milking. Subsequent 
 examination showed that the plate exposed out of 
 doors received six bacteria, while that exposed in 
 the barn received one hundred and eleven bacteria, 
 and that exposed under the cow received one thou- 
 sand eight hundred bacteria. If one thousand eight 
 hundred bacteria will fall from the belly of a cow 
 during milking in a circle three and one-half inches 
 in diameter in two minutes, one can easily appre- 
 ciate the immense number that Avill fall into an or- 
 dinary milk pail during the whole period of milking. 
 This, however, is only one of the sources of con- 
 
tamination. The milkman, wearing clothes from which 
 much dust falls, leans forward over the pail, his arms 
 especially being shaken over the pail. The friction 
 between the milkman's hands and the teats of the 
 cow causes the removal of the dirt and epithelium 
 from both the hands of the milkman and the teats of 
 the cow. This friction is often lessened by what is 
 known as wet milking. When this is practised, a 
 stream of milk from the teat is directed against the 
 palms of the milkman's hands, first one hand and 
 then the other, the hands being then applied to the 
 teats. The result is that the teats of the cow and the 
 palms of the hand of the milkman are practically 
 washed over the milk pail and drops of milk expressed 
 from between the hand and the teat fall into the pail 
 below. A less important but still material source of 
 contamination is the dust of the barn. In the illustra- 
 tions to which I have already called attention (Figs. 
 I and 2) it is seen that while only six bacteria fell into 
 the plate out of doors, one hundred and eleven fell 
 during the same time in the barn. 
 
 Contamination of milk by impure water is of 
 frequent occurrence. Such water is often used in 
 washing the pails, or it may be introduced into the 
 milk by submersion of the milk in pails or cans in 
 contaminated water for cooling. Or adulteration of 
 milk with dirty water may occur. The quality of the 
 water used in many dairies has apparently received 
 little attention. 
 
 It is thus seen that during and immediately after 
 milking, an extensive contamination of the milk takes 
 place, and by no practicable method yet adopted has 
 it been possible to entirely prevent it. Fresh milk 
 appears to have some germicidal action. The writer 
 has found a constant diminution in the number of 
 bacteria in certain specimens of milk during the first 
 twelve hours after milking. Fokker'' has reported 
 similar results, noting a diminution in the number of 
 bacteria during the twenty-four hours after milking. 
 Such germicidal action of milk, however, cannot be 
 depended on, for milk will sometimes sour within 
 twenty-four hours after milking. It is, therefore, de- 
 sirable that milk should be kept cold and consumed 
 or sterilized within twenty-four hours after milking. 
 The influence of temperature on the growth of bac- 
 teria in milk was well shown by the following experi- 
 ment : From a specimen of milk a certain amount 
 
was put in four sterilized test tubes. TiTese samples 
 were left for twenty-four hours at different tempera- 
 tures. At the end of twenty-four hours a fixed amount 
 from each sample was planted in a plate and the 
 number of colonies that developed in each plate was 
 counted. A photograph of the plates at the time the 
 counts were made is shown (Figs. 4, 5, 6, 7). The one 
 kept at 7° C. (45° F.) had 445 colonies; that at 10° C. 
 (50° F.) 1,362 colonies; that at 13° C. (55° F.) 
 67,170 colonies; while the. one at 20° C. (68° F.) 
 showed 134,340 colonies. Such experiments show 
 that milk should be kept at a temperature below 10° 
 C. (50° F.) until sterilized or consumed. It has been 
 stated already that milk should not be kept raw for 
 more than twenty-four hours. New York milk, even 
 that of the better sort which is brought to town in 
 bottles and sold at eight or ten cents a quart, is usu- 
 ally thirty-six or forty-eight hours old when delivered 
 to the consumer. Some milk shipped to New York 
 from a distance of over three hundred miles is actu- 
 ally nearly twenty-four hours old when shipped. 
 The transportation of milk is by milk trains, which 
 are very slow, often making only seventeen miles an 
 hour. 
 
 A consideration of the foregoing statement prepares 
 one for the results of the examination of ordinary Ne\A' 
 York milk, which often contains from a hundred thou- 
 sand to several million bacteria in each drop. Our 
 present dairy methods allow ample opportunity for the 
 entrance of bacteria, either non-pathogenic or even 
 pathogenic, should the latter sort be present. The 
 long interval between milking the cow and delivering 
 the milk to the consumer allows ample opportunity 
 for the bacteria to multiply. 
 
 Disease Conveyed by Milk. — The diseases which, 
 it is believed, may be conveyed by milk are conven- 
 iently divided into three classes: 
 
 I. Those in which the pathogenic micro-organisms 
 which are introduced into the milk are conveyed from 
 the body of the diseased cow, as tuberculosis, an- 
 thrax, foot-and-mouth disease, and acute enteritis. 
 
 II. Those in which the pathogenic micro-organisms 
 are introduced into the milk from some other source 
 either during or after milking, as cholera, typhoid 
 fever, scarlet fe\er, and diphtheria. 
 
 III. Those caused by milk which contains poison- 
 ous agents developed by bacterial growth. 
 
lO 
 
 I. Diseases Conveyed by Milk from a Diseased 
 Cow. — Contamination of milk with disease germs 
 ■which emanate from the cow may occur while the milk 
 is still in the udder, in the case of certain general dis- 
 eases and especially in diseases of the udder, or the 
 contamination may take place during milking by the 
 dropping of particles of fsecal matter from the cow or 
 from the dust of the barn, which may contain dried 
 particles of faecal material or saliva of the cow. 
 
 Liability to Faecal Contamination of Milk Dur- 
 ing Milking Most cases of contamination of milk 
 
 with disease germs originating from the cow have 
 been attributed to milk infection in the udder; on 
 the other hand it is evident that contamination is very 
 liable to occur from dried particles of fsecal matter 
 dropping into the pail, especially when the animal is 
 having loose evacuations. Socrates, as quoted by 
 Xenophon in his " Memorabilia," discourses on the 
 wisdom of the gods in placing our eyes, nose, and 
 mouth in the position which they occupy, and " since 
 what passes off from the stomach is offensive, to turn 
 the channels of it away and remove them as far as 
 possible from the senses." Had the wise Socrates 
 pursued his observations in a dairy, I fear he would 
 have been inclined to criticise the judgment of these 
 deities in the case of the cow in turning her channels 
 loose just above the udder, thus not only endangering 
 the sucking calf, but making the inevitable position 
 of the milk pail one of considerable hazard. Watery 
 evacuations from a cow pass naturally along its thighs 
 and on to the posterior portion of the udder. It is 
 not unusual in a dairy to see an udder that is soiled 
 by faecal matter with large dried masses hanging by 
 its hair, and these are shaken over the pail during 
 milking. 
 
 Tuberculosis in Cattle. — Tuberculosis is prob- 
 ably the most important of those diseases whose germs 
 are liable to be conveyed by milk and in which the 
 contamination of the milk may arise from the cow. 
 It is a very prevalent disease, existing to the greatest 
 extent in the neighborhood of large cities. Estimates 
 as to the proportion of cattle that are tuberculous in 
 different sections of this country and abroad vary 
 widely. Those estimates which are based simply on 
 the opinions of veterinarians from physical examina- 
 tion alone should be rejected as unreliable. Slaugh- 
 ter-house statistics furnish definite information, al- 
 
1 1 
 
 though some cases with but slight tuberculous disease 
 undoubtedly pass unrecorded. 
 
 In the following table is given the percentage of 
 cattle reported tuberculous in the slaughter houses 
 of certain cities and countries : 
 
 Berlin" 4.57;^ 
 
 Munich" 2 . 44;^ 
 
 Augsburg" 2.24^ 
 
 Mulhausen' 3.4^; 
 
 Hanover" 60-70^ 
 
 France* 5^ 
 
 Paris" (3% 
 
 Holland" 20f,; 
 
 Pomerania" 50^ 
 
 Mexico' 34;; 
 
 The use of tuberculin followed by autopsy in 
 cases where a significant reaction is obtained gives 
 a basis of statistics which should indicate a larger 
 percentage of tuberculous animals than any other, 
 for tuberculin will give a reaction where lesions exist 
 that are so small that they might easily be overlooked 
 in any ordinary physical examination or even au- 
 topsy. 
 
 Statistics derived from the use of tuberculin will 
 never be quite satisfactory so long as herds are ex- 
 amined with tuberculin only when the owner requests 
 such an examination. In Massachusetts " more than 
 one-fourth of the cattle in herds examined by request 
 are found to be tuberculous, the percentage of tuber- 
 culous cows in a herd varying from 0.9 to 95 per cent. 
 In New York State ° the use of the tuberculin test has 
 made it seem probable that nearly seven per cent, of 
 all the cattle of the State are tuberculous. 
 
 A consideration of these statistics leads one to 
 inquire whether all tuberculous cows produce milk 
 containing the Bacillus tuberculosis. Do tubercle 
 bacilli appear in the milk only when there is disease 
 of the udder, or may they be present when the cow 
 has general tuberculosis but no lesion of the udder.'* 
 Bang ° found that of sixty-three cows having general 
 tuberculosis, but no nodules in the udder, nine gave 
 milk containing the bacillus tuberculosis. Ernst '" 
 found the Bacillus tuberculosis present in a much 
 larger proportion of cows having general tuberculosis, 
 but no evident involvement of the udder. By a very 
 thorough examination of stained specimens of milk of 
 thirty-six such cows, the Bacillus tuberculosis was 
 found in twelve or thirty-three per cent. Moreover, 
 
12 
 
 it should be remembered that milk from a cow with 
 general tuberculosis which is free from tubercle ba- 
 cilli when it leaves the udder of the cow may become 
 contaminated during milking. Should such a cow 
 have a tuberculous enteritis and pass tubercle bacilli 
 in its feeces, its milk is very liable to become con- 
 taminated by the dropping of dried particles of 
 fffical material from the posterior portion of the ud- 
 der during milking. 
 
 Action of Gastric Juice on the Bacillus Tuber- 
 culosis. — Considering the immense amount of milk 
 used, the large amount of tuberculosis among cattle, 
 and the fact that cows with no lesion of the udder may 
 produce milk containing tubercle bacilli, one may 
 be surprised that milk does not produce more tuber- 
 culosis in men. A certain amount of protection is 
 provided by the mixing of milk in large cans, thus, 
 so to speak, diluting the virus. 
 
 Gebhardt " found that milk of tuberculous cows 
 which was virulent when pure lost its virulence when 
 diluted, in some cases forty times, in others fifty or 
 one hundred times. 
 
 Cooking and sterilizing milk also renders a con- 
 siderable amount innoxious. 
 
 It has been thought that a protection may be pro- 
 vided by a germicidal action of the gastric juice on 
 the tubercle bacilli. That such protection is not af- 
 forded by the gastric juice of guinea-pigs has been 
 shown by experiments of Baumgarten'" and of Fischer," 
 nor by artificially prepared gastric juice by those of 
 Falk." In fact, primary intestinal tuberculosis in 
 man does occur. Dr. Sims Woodhead'^ states that 
 he has seen a very large number of cases in which 
 infection seemed to be from the intestine. Cohnheim, 
 Aufrecht, and Peterson " hold the same view. Three 
 cases of evident primary tuberculosis of the intestine 
 have been reported in this city recently : one in an 
 adult by Dr. Hodenpyl " and cases in infants by Dr. 
 Northrup," and by Dr. J. Lewis Smith, and the writer.'* 
 
 Clinical Evidence of the Transmission of Tuber- 
 culosis by Milk. — Clinical evidence of the transmis- 
 sion of tuberculosis by milk is less satisfactory than 
 that furnished by some other diseases on account of 
 the less acute character of this disease and the vary- 
 ing degree of susceptibility to it in different individ- 
 uals. Some cases, however, are reported in which the 
 evidence against the milk is fairly strong. Thus, in a 
 
13 
 
 dairy in England '" tliree cows were found to have tu- 
 berculous disease of the udder. In the institution to 
 ■which this milk was supplied the mortality from tu- 
 berculosis during the last year was thirty per cent, and 
 during the preceding year forty per cent, of the total 
 mortality. Brouardel " reported that in a boarding- 
 school in which there were fourteen girls five contracted 
 tuberculosis from drinking the milk of a tuberculous 
 cow. Ollivier"' tells of another boarding-school 
 in which milk from a tuberculous cow was used and in 
 which thirteen cases of tuberculosis occurred. Dr. 
 Demme " states that in the Child's Hospital at Berne 
 four infants, with no tuberculous ancestry, died of in- 
 testinal and mesenteric tuberculosis as the result of 
 feeding on the unsterilized milk of a tuberculous 
 cow. Many cases have been reported in which, from 
 .among a number of persons using the milk of a single 
 cow, one child has died of tuberculosis. ' There has 
 been no tuberculous family history and no known con- 
 tact with any tuberculous person. The only apparent 
 source of infection has been the milk. The cow from 
 which the milk was obtained has been examined and 
 found tuberculous. Such cases the writer has thought 
 best not to include in this paper, as the evidence 
 seemed insufficient although significant. 
 
 It may be considered an established fact that tuber- 
 culosis may be induced in man by drinking raw milk 
 from a cow suffering from tuberculosis. 
 
 Anthrax. — Concerning anthrax there is some evi- 
 dence that it is communicated by milk, although it is 
 not altogether satisfactory. The anthrax bacillus has 
 been found in the milk of animals suffering from an- 
 thrax by Nocard^' and others. The clinical evidence 
 seems to rest largely with Heusinger, " who wrote in 
 1850, and in whose statements German writers place 
 considerable confidence. Heusinger said that it was 
 proved that milk and butter from animals suffering 
 from anthrax possess virulent properties by numer- 
 ous observations in America and Russia, and that the 
 malady produced was the milk sickness of America. 
 Heusinger was evidently in error in his opinion that 
 anthrax and milk sickness are identical. Milk sick- 
 ness certainly differs in symptoms and prognosis from 
 intestinal anthrax. I have found no American writer 
 who associates the two diseases. 
 
 Foot-and-Mouth Disease. — That foot-and-mouth 
 disease may be communicated by milk has been 
 
demonstrated experimentally. Hertwig "" and two 
 friends drank daily for four days a quart of milk each 
 from a cow suffering from foot-and-mouth disease. 
 In less than two days the symptoms of the disease ap- 
 peared in each and lasted five days. The mucous 
 membrane of the mouth became swollen and on that 
 covering the inner surface of the cheek small vesicles 
 appeared. Vesicles appeared also on the hands in one 
 case. The results of Hertwig were confirmed by Jacob. 
 
 In 1884 an epidemic" occurred in Dover, England, 
 which involved one hundred and thirty consumers of 
 the milk of one milkman. The attacks were charac- 
 terized by shivering followed by headache, fever, pain 
 in limbs, thirst, parched lips, and a vesicular erup- 
 tion of the throat. On one of the farms supplying 
 this milkman the cows were found to have been suf- 
 fering from foot-and-mouth disease. Other cases of 
 foot-and-mouth disease transmitted to man by milk 
 are reported by Weigel and Noack,"" Schaffer and 
 Esser,'" Esser and Schiitz,''" and Weissenberg.^' In 
 this country foot-and-mouth disease is comparatively 
 unknown. 
 
 Acute Enteritis. — Another disease which has been 
 demonstrated to have been caused by milk infected 
 by the cow is acute enteritis. The following case re- 
 ported by Gaffky '" is particularly interesting, since the 
 milk in the cow's udder contained no bacteria, the 
 bacteria being introduced into the milk probably dur- 
 ing milking from the dried particles of faecal matter 
 on the posterior portion of the udder, which, during 
 milking, fell into the pail. This case presents so 
 much good evidence that I will briefly review it. On 
 October 10, 1891, three men connected with the Hy- 
 gienic Institute at Giessen were suddenly taken sick; 
 they were the assistant, the chemist, and the janitor. 
 
 They had chills, fever, diarrhoea, and constitutional 
 symptoms. The assistant was very sick for two 
 weeks, his temperature reached 106° F., he was deliri- 
 ous, passed blood with his stools, and had albuminu- 
 ria. The chemist had the same sort of illness, but 
 less severely, his temperature never rising above 
 104.7° F- The janitor again had the same type of 
 illness but still less severely, with a temperature never 
 above 104° F. On investigation it was found that 
 the only article of diet of which they had all partaken 
 was milk. The assistant had a litre of milk in the 
 laboratory the previous daj', of which he had taken 
 
15 
 
 more than half for his breakfast; the chemist liad 
 taken one cup, while the janitor had less than that, 
 finishing what was left. This milk was traced to a 
 cow that was suffering from hemorrhagic enteritis and 
 passing watery fseces containing blood clots. The 
 milk of this cow as it left the udder contained no 
 ^erms. In the faeces a short active bacillus was 
 found, which proved very pathogenic for mice and 
 guinea-pigs, and which corresponded to what had al- 
 ready been found in the stools of the patients. Here, 
 then, we have a clear case of fa;cal contamination of 
 the milk from the cow. 
 
 In Manchester, England, in November, 1894, an 
 epidemic occurred"" characterized by diarrhoea, sick- 
 ness, and abdominal pain. There were one hundred 
 and sixty cases in forty-seven houses, all served by 
 the same milkman, they being fifty per cent, of all the 
 houses he served. This was referred to a case of 
 garget in a cow at the dairy. 
 
 II. Diseases Conveyed from One Human Being 
 to Another by Milk. — Passing now to those diseases 
 in which milk appears to be a carrier of infectious 
 material through contamination by some person suf- 
 fering from one of these diseases, we must first note 
 that evidence of such contamination has not been 
 demonstrated bacteriologically. Although typhoid 
 fever, cholera, diphtheria, and scarlet-fever epidemics 
 have been attributed to milk, in no case, so far as I 
 know, has it been possible to demonstrate the particu- 
 lar organism in the specimen obtained. The organism 
 of scarlet fever is not known, but those of typhoid 
 fever, cholera, and diphtheria are familiar to bacteri- 
 ologists. From this negative bacteriological evidence 
 some writers are disinclined to accept the evidence 
 we have as conclusive. 
 
 Characteristics of Epidemics Due to Milk. 
 — There are certain characteristics of epidemics due 
 to milk, whether they be epidemics of typhoid fever, 
 scarlatina, diphtheria, or gastro-enteritis, which it 
 may be well to point out. 
 
 1. The cases appear suddenly, many new cases 
 each day, and the subsidence is equally marked a few 
 days after stopping the harmful milk supply. 
 
 2. The houses invaded are often widely distributed 
 and not restricted to some particular part of the town. 
 
 3. The houses of the rich are apt to be more seri- 
 ouslv invaded than those of the poor, because poor 
 
i6 
 
 people as a rule use very little milk. The houses 
 invaded often have the best hygienic surroundings 
 and frequently they have a different water supply and 
 a different sewage system from others in which the dis- 
 ease exists, so that these possible causes of the epi- 
 demic may be eliminated. In the Yorktown and 
 Camberly epidemic of diphtheria due to milk in 1887, 
 while eighty-four per cent, of the houses of the better 
 class using the milk were invaded, only twenty-two 
 per cent, of the poorer class using the milk were 
 invaded, and while thirty-three per cent, of the con- 
 sumers of the better class acquired diphtheria, only 
 six per cent, of those of the poorer class acquired 
 it. 
 
 4. The special milk drinkers in each family are 
 most liable to become affected. Thus in the epidemic 
 I have quoted seventy-eight per cent, of the special 
 milk drinkers were affected, while only twenty-seven 
 per cent, of those not special milk drinkers were 
 affected. Those who take but little of the infected 
 milk are not, however, exempt from the disease. In 
 a recent epidemic of typhoid fever caused by milk, one 
 gentleman who carefully procured his milk from an ex- 
 cellent dairy inadvertently purchased ice cream with- 
 out inquiring the source of the milk from which it 
 was made. The ice cream had been made from the 
 milk of the infected dairy ; the result was the death 
 of one child from typhoid and the illness of all the 
 other members of the family, including the father, 
 mother, and one other child. 
 
 5. Children are most liable to be affected. In the 
 Stamford epidemic of typhoid fever out of three hun- 
 dred and eighty-six cases one hundred and thirty-four, 
 or 34.8 per cent., were children, although the greatest 
 liability to typhoid exists between the ages of twenty 
 and thirty. In the Yorktown and Camberly epidemic 
 of diphtheria, while only 17.6 per cent, of the adult 
 drinkers of the milk were affected, 30.2 per cent, of 
 the children suffered. 
 
 6. In the epidemics those affected are found to be for 
 the most part the drinkers of a certain milk supply — in 
 Stamford, 376 of a total of 386; in Springfield, Mass., 
 135 of 150; in Somerville, Mass., 30 of 35; in Man- 
 chester, England, 107 of 115. In some other epidem- 
 ics, as may be seen by the tables near the end of this 
 article, all the cases were among drinkers of the con- 
 taminated milk. When it is found that the same 
 
17 
 
 milkman does not supply most of the houses invaded, 
 it is sometimes found that several milkmen obtain 
 their supply from one dairy and that in this dairy 
 the infection has taken place. In other epidemics 
 but a small proportion of the suspected milkman's 
 route is invaded, as in Springfield, and this is on in- 
 vestigation explained by the fact that the milkman 
 obtained but a small proportion of his milk from the 
 farm where the infection took place. 
 
 7. In more than half of these epidemics due to 
 milk cases of the disease preceding the epidemic have 
 been found among the milk handlers. When such 
 cases have not been found, it is usually not possible 
 to say that they have not existed. 
 
 Typhoid Fever. — In the case of typhoid fever we 
 have a large amount of evidence which, while it is 
 circumstantial, is at the same time very conclusive. 
 Although the Bacillus typhosis has not been found in 
 any of the specimens examined, it does not follow 
 that it was not present at the time the epidemic was 
 started. The organism of typhoid fever thrives in 
 milk. It does not seem possible that any one who 
 has studied the recent literature concerning epidemics 
 of typhoid fever due to milk could doubt the causa- 
 tive relation of the contaminated milk. Very many 
 outbreaks of this sort have been inadequately reported 
 without exact statistics and some have never been re- 
 ported at all. We have, however, a sufficient number 
 which have been capably investigated and accurately 
 reported to furnish conclusive evidence. Ernest 
 Hart collected fifty outbreaks of typhoid due to milk 
 previous to 1881. I have collected fifty-three occur- 
 ring between i88i and 1895, which are tabulated near 
 the end of this article. In all these the evidence was 
 fair, while in certain of them it seems to me abso- 
 lutely conclusive, as in the recent Stamford epidemic, 
 in which the distribution of cases followed almost ex- 
 actly the milk route of the offending milkman; or that 
 at Bay Head, where fifteen out of the sixteen cases 
 were among the drinkers of the milk from a dairy 
 where an employee had suffered from typhoid; or that 
 at Montclair, N. J., where one hundred and thirty-five 
 out of a total of one hundred and fifty cases were 
 among drinkers of milk from a filthy dairy, the owner 
 of which had himself suffered from typhoid just pre- 
 vious to the epidemic. Compare these statistics with 
 those of epidemics due to polluted water. In the 
 
Lowell and Lawrence, Mass., epidemic of 1891,'' for 
 instance, of four hundred and eighty cases only fifty 
 were supplied by one milkman, while the cases oc- 
 curred among the customers of one hundred and thirty- 
 five milkmen. Of the fifty-three outbreaks of typhoid 
 fever which I have collected and tabulated, ten oc- 
 curred in this country and thirty-one in Great Britain. 
 These epidemics were distributed pretty equally dur- 
 ing the year. I note the months in which thirty-three 
 of these epidemics occurred, some, of course, running 
 through several months, as follows: January, 4; Feb- 
 ruary, 4; March, 6; April, 4; May, 5; June, 5; 
 July, 6; August, 10; September, 4; October, 3; 
 November, 4; December, 4. The greatest number 
 (ten) occurred in August, while the smallest num- 
 ber (three) occurred in October. Of fifty-one epi- 
 demics,^'^ in thirty-three a case of probable or posi- 
 tive typhoid was found, which was believed to have 
 caused the contamination of the milk. In six the 
 water used was polluted (and in one of these was 
 found to contain the Bacillus coli communis), while 
 in two the premises were found in bad condition. 
 In thirty-one epidemics a case of typhoid was found 
 to have occurred in the house of the farmer or milk- 
 man preceding the epidemic. The means of trans- 
 mission of the typhoid germs in these epidemics was 
 simple. In some cases the typhoid existed in a mild 
 form, so that the patient actually worked in the dairy. 
 Often the same person nursed the patient and worked 
 about the dairy, sometimes milking the cows. The 
 dairy pails were often washed in the kitchen, which in 
 one case opened into the sick-room, and the same 
 towel may be used for the patient and for drying and 
 cleaning the pails, or the privy may be found close to 
 the dairy well, no disinfection of fseces having taken 
 place. In one place (Springfield) the contents of the 
 privy in which the stools of a typhoid patient were 
 deposited were spread over a field through which the 
 farm laborers walked, thus affording opportunity for 
 infecting their shoes. The milk was cooled by sub- 
 merging it in a well covered by boards on which lay 
 lumps of manure. Before being submerged the milk 
 cans were stoppered by wooden plugs. There was 
 some leakage around these plugs in four of nine cans 
 tested, so that the water from the well entered the 
 cans. The water of this well was found to contain 
 the Bacillus coli communis, thus giving evidence of 
 
19 
 
 fftcal contamination. In some epidemics, in which 
 the disease has occurred mostly among the consumers 
 of one milk supply, no typhoid fever has been found 
 either at the dairy or in the family of the milk- 
 man. Among these there has been found, in different 
 cases, a sewage field near the dairy, a tank of filthy 
 water at the dairy, a sewer trap within a foot of the 
 well. It does not of course follow that because no evi- 
 dence of infection of milk by a person can be secured 
 that therefore such infection did not take place. In 
 the investigation of epidemics it has always been 
 most difficult to secure the facts, since those who pos- 
 sess them are very unwilling to communicate them, 
 fearing injury to their business. 
 
 A new danger due to modern methods of handling 
 milk is the creamery. It is the custom at creameries 
 to receive from the farmers in the neighborhood milk 
 which is mixed in the separator, and after separation 
 the skim milk is returned to the farmers in the pro- 
 portion in which it was contributed. In three re- 
 cent epidemics (Svarteborg, 1889, one reported by 
 Welpey, 1893, and that at Castle-Island, Ireland, in 
 1894) the disease appeared first in one of the con- 
 tributing farms and spread through the contamination 
 •of the milk at the creamery to the other contributors. 
 In the epidemic reported by Welpey all the twenty- 
 three cases occurred among contributors to the cream- 
 ery. Attention having been called to this danger, the 
 authorities in some places have taken steps to control 
 it. In a recent number of the British Medicaljournal 
 it was stated that during a serious outbreak of typhoid 
 fever at Castle-Island, Ireland, the proprietor of a 
 •creamery was fined £5 for accepting milk from farms 
 on which typhoid fever existed. 
 
 Scarlatina. — In studying the relationship of scar- 
 latina to the milk supply, we find some very conclu- 
 sive evidence that certain epidemics of this disease 
 have been caused by contaminated milk. In about the 
 same proportion of the cases, however, as in typhoid 
 fever do we find evidence of the contamination of the 
 milk by a person suffering from scarlatina. Thus, of 
 twenty-six recent epidemics, all occurring in England, 
 in fifteen cases there was evidence of contamination 
 from a case of the disease in man. The lack of such 
 evidence in some cases has directed attention to the 
 condition of the cows furnishing the milk, although 
 it may be accounted for by the high degree of conta- 
 
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 Remarks, 
 
 Traced to a cow suffering from hemor- 
 rhagic enteritis. The same bacillus 
 was isolated and cultivated from the 
 cases and the cows. This bacillus was 
 found to be pathogenic for mice and 
 guinea-pigs. 
 
 Occurred in a hospital. Nine out of ten 
 men were affected with nausea, vomit- 
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 fauces, vertigo, colic, and purging. A 
 residue extracted from the milk pro- 
 duced similar symptoms. 
 
 Nausea, vomiting, cramps, and collapse. 
 Recovery in a few hours. 
 
 A whole family was attacked with diar- 
 rhoea and bloody stools after drinking 
 milk from a cow similarly affected and 
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 Milk adultered with water from a tank 
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 Reference. 
 
 Deut._ med. Woch., '92, 
 xviii., 14. 
 
 Practitioner, '87, xxxix. , 75. 
 
 Rep. B. of H., N. J., 
 
 1885-86. 
 Schmidt's Jahrb., vol, ccv., 
 
 p. 131, 
 
 Practitioner, xxxix., p, 144. 
 
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29 
 
 giousness of the disease and the fact that very mild 
 cases occur which can never be recognized except as 
 they occur with others. A series of publications by 
 Klein attribute some of these epidemics to slight 
 lesions about the udder and teats of the cows produc- 
 ing the milk which caused the sickness. Klein's 
 work, however, has never been confirmed. It seems 
 to me a humiliating fact that not one epidemic of 
 scarlet fever due to contaminated milk, so far as I 
 have found, has been reported in this country. This 
 is not in all probability because they do not occur, 
 but for the reason we all know to exist, because the 
 source of milk supply is not ordinarily inquired into. 
 It should certainly be the duty of all inspectors of 
 boards of health to ascertain the milk supply of each 
 family in which any case of contagious disease 
 occurs. 
 
 Diphtheria Some epidemics of diphtheria have 
 
 been found to exist almost solely among the consum- 
 ers of a certain milk supply. Diphtheria epidemics 
 traced to milk are, however, less common than those of 
 scarlet fever. In only five of eleven epidemics of 
 diphtheria traced to milk that I have tabulated was 
 any diphtheria found at the dairy. Of the seven epi- 
 demics reported by Hart, in only one did he find 
 diphtheria at the house of the milk dealer. In cer- 
 tain of these epidemics the cows have been suspected 
 of being the cause on account of a contagious erup- 
 tion on the teats or a ropy consistency or unpleasant 
 taste of the milk. These observations concerning the 
 animals are strongly opposed by many authorities, 
 and should not be considered until more evidence is 
 produced, for many light cases of true diphtheria 
 exist which do not produce severe constitutional 
 symptoms. It is not altogether improbable that all 
 these epidemics may have been caused by diphtheria 
 in man, and that either the man was unaware that he 
 had the disease or that its existence was not known to 
 the authorities. The Bacillus diphtheria; grows well 
 in milk. Of thirteen epidemics of diphtheria attrib- 
 uted to milk contamination, one occurred in January, 
 none in February or March, one in April, two in May, 
 four in June, four in July, three in August, none in 
 September, three in October, two in November, and 
 four in December, while in two the month in which 
 they occurred is not stated. All but two of them oc- 
 curred in Great Britain and one was reported in this 
 
30 
 
 country. One of these epidemics, that at Yorktown 
 and Camberly, reported by Power, presents so many 
 instructive features that it seems worth while to point 
 to some of them as illustrating certain characteristics 
 of epidemics due to milk. One hundred and forty 
 persons in fifty-seven households were taken sick in 
 October and ninety per cent, of these during an in- 
 terval of ten days between October 8th and i8th. 
 Of the fifty-seven households affected, forty-eight, or 
 84.2 per cent., had the suspected milk, and of the 
 one hundred and forty persons, one hundred and 
 twenty-four, or 88.5 per cent., drank the suspected 
 milk. Rich people were attacked in larger proportion 
 than the poor, and this fact would seem to be accounted 
 for by the fact that rich people consumed an average of 
 over five pints a day, while poor families averaged less 
 than a pint each. While eighty-four per cent, of the 
 families of the better class were affected, only twenty- 
 two per cent, of the families of the poorer class were 
 affected. Thirty-three per cent, of consumers of the 
 better class were affected and only six per cent, of 
 those of the poorer class. In these statistics also we 
 have an example of the greater liability of children on 
 account of the amount of milk they consume, for while 
 twenty-nine per cent, of the adults of the better class 
 were affected, fifty-four per cent, of the children of 
 the better class were affected. These statistics also 
 show the greater susceptibility of special milk drink- 
 ers, for, while only twenty-seven per cent, of the con- 
 sumers who were not special milk drinkers were at- 
 tacked, seventy-eight per cent, of the special milk 
 drinkers were attacked. And again, among children 
 ten per cent, of those not special milk drinkers were 
 attacked, while seventy per cent, of the special milk 
 drinkers sickened. It was also found that cream 
 drinkers were not more affected than those using 
 milk. A valuable lesson is taught in the fact, that on 
 account of the larger amount of milk consumed, it is 
 much easier to trace such an epidemic to its source by 
 investigations among the well-to-do than among the 
 poor. 
 
 Cholera Asiatica. — That cholera may be spread by 
 milk we have good reason to believe. The bacillus 
 of cholera grows well in milk when it has been previ- 
 ously sterilized. It is, however, considered that its 
 growth in milk may be retarded by the presence of 
 many other bacteria. Basenau '" has found cholera 
 
bacilli active in raw milk thirty-two hours after their 
 introduction in se\eral experiments at different tem- 
 peratures. Gaffky," who has written on cholera in 
 India and Egypt and is considered a reliable observer, 
 says that milk is not infrequently a means of com- 
 municating cholera. An epidemic of cholera on ship- 
 board reported by Simpson " furnishes conclusive evi- 
 dence of infection through milk. Of the ten sailors 
 who drank the milk, all had cholera, while of the re- 
 maining fourteen members of the crew only one had 
 cholera. The milk was furnished by a man who did 
 washing for the crew. He afterward acknowledged 
 that he mixed the milk with one-fourth part of water 
 from a tank. The water from this tank was found to 
 have caused an epidemic of cholera in the neighbor- 
 hood. 
 
 III. Diseases Caused by Milk which Contains Poi- 
 sonous Agents Developed by Bacterial Growth. — 
 Cases of poisoning by milk and milk products have 
 been reported. A serious case of milk poisoning sup- 
 posed to have been caused by a ptomaine occurred at 
 Long Branch in 1885." On the 7th of August forty- 
 three persons at two different hotels were attacked 
 with nausea, vomiting, cramps, and collapse from one 
 to four hours after taking the milk. They recov- 
 ered in a few hours. A week later thirty people at 
 another hotel had the same experience. All these 
 people had milk from the same source and only milk 
 drinkers were attacked. The dairy and cattle showed 
 no cause for criticism except that the milking took place 
 at midnight and noon, and the milk was not cooled 
 but was carted immediately to Long Branch, eight 
 miles distant. In this case the test for the so-called 
 tyrotoxicon of Dr. Vaughn was applied with a posi- 
 tive result. Another case of so-called ptomaine poi- 
 soning is reported by Firth.'" 
 
 Summary In summing up we may conclude that 
 
 infection by milk is well established in typhoid fever, 
 scarlatina, diphtheria, tuberculosis, cholera, foot-and- 
 mouth disease and acute enteritis, and that it may exist 
 in anthrax. Cases of acute poisoning from milk by 
 some undetermined agent also occur. Medical litera- 
 ture furnishes us with reliable evidence of an im- 
 mense amount of sickness and a considerable death 
 rate caused by milk. The recorded epidemics are 
 but a part of those which occur. Many epidemics are 
 never traced to their source and some which are so 
 
32 
 
 traced are not reported. This sickness and death 
 directly due to contaminated milk is to a great extent 
 preventable by proper legislation concerning the in- 
 -spection of dairies and the handling of milk. 
 
 A Study of these Epidemics Teaches Us — i. 
 Whenever a case of communicable infectious disease 
 is reported inquiry into the source of the milk supply 
 should be made. 
 
 2. Milk traffic should be separated from houses 
 where people live. The dairy building should be at 
 least one hundred feet from either the house, barn, or 
 privy, and should be on a higher level than any of 
 these, and should have a pure water supply of its own. 
 At this dairy building all the dairy work should be 
 done, including the cleansing of pails and cans. 
 
 3. It should be unlawful for any one who has come 
 in contact with a sick person (when this sickness is 
 not positively known to be non-contagious) to enter 
 the dairy building or barn or to handle the milk. 
 
 4. All men connected with the milk traffic should 
 be compelled to notify the authorities on the outbreak 
 of any disease in their respective abodes and to ab- 
 stain from their work until permission to resume is 
 given them by the authorities notified. 
 
 5. Cities should accept milk only from dairies 
 which are regularly inspected and where all the cows 
 have been tested with tuberculin and those giving the 
 •characteristic reaction have been killed and the prem- 
 ises disinfected. 
 
 6. The tuberculin test should be applied to all cat- 
 tle and those which react should be killed, the owner 
 being reimbursed from State funds. The premises on 
 which such tuberculous cattle have been kept should 
 be thoroughly disinfected. All cattle which are 
 brought into the State should be quarantined until 
 the tuberculin test has been applied. 
 
 7. The use of one long trough for the purpose of 
 feeding many cattle should be avoided, since it is a 
 ready means for the conveyance of pathogenic germs 
 from one animal to another. 
 
 From the excellent regulations of the New York 
 City Board of Health for the sale and care of milk 
 I take the following important rule: "Milk shall not 
 be kept for sale or stored in any room used for sleep- 
 ing or domestic purposes or opening into the same." 
 
 Undoubtedly the adoption of the above regulations 
 ■would do much in reducing the amount of sickness 
 
■due to the conveyance of pathogenic organisms by 
 milk. It does not seem probable, however, that any 
 regulations can entirely eliminate this danger. 
 
 I would, therefore, add one word of caution for 
 physicians who order milk diet. Use some sufficient 
 sterilizing process, so that in case the milk supplied 
 contains pathogenic organisms, they may be destroyed 
 before the milk is used by the patient. 
 
 BIBLIOGRAPHY. 
 
 1. Mart: Trans. Int. Med. Cong., London, 1881, iv., page 491. 
 
 2. Armstrong: Practitioner, London, 1892, vol. xlviii., page 224. 
 
 3. Law: Medical Record, 1895, ii., page 731. 
 
 4. Fokker: Fortschritte der Medicin, 1890, page 7. 
 
 5. Rouvier: Le Lait, Paris, 1893, page 149. 
 
 6. Shumway: Handb. of Tuberculosis, etc., Boston, 1895. 
 
 7. Peters: Bost. Med. and Surg. Journal, 1894, ii., page 525. 
 
 8. Osgood: American Med. -Surg. Bui., 1895, page 1,437. 
 g. Bang: Schmidt's Jahrb., ccxxxv., page 22. 
 
 10. Ernst: Infectiousness of Milk, Boston, 1895. 
 
 11. Gebhardt: Virchow's Archiv, 1890, cxix., page 12. 
 
 12. Baumgarten: Lehrbuch d. Path. Mykologie, 1890, page 
 
 54y- 
 
 13. Fischer: Arch, fiir Exp. Path. u. Pharm., 1886, xx., page 
 446. 
 
 14. Falk: Virchow's Archiv, 1883, xciii., page 177. 
 
 15. Woodhead: Med. Press and Circular, London, i88S, xiv., 
 page 265. 
 
 16. Wurzburg: Therapeutische Monatshefte, 189I, page 18. 
 
 17. Hodenpyl: Medical Record, 1895, i., page 313. 
 
 18. Northrup: Proceedings of New York Path. Society, 1890, 
 page 42. 
 
 19. Smith and Freeman: American Med. -.Surg. Bui., 1895, 
 page 1,461. 
 
 20. Woodhead: Med. Press and Circular, 1888, xiv., page 265. 
 
 21. Rouvier: Le Lait, page 154. 
 
 22. OUivier: Ilul. de I'Acad. d. Jled., 1891, Iv., page 288. 
 
 23. Demme: Cornell University Agricultural Experiment Sta- 
 tion Bui., Ixv., page 137. 
 
 24. Nocard: Br. Med. Journal, 1885, i., page 713. 
 
 25. Heusinger: Die Milzbrandkrankheiten der Thiere und des 
 Menschen, Erlangen, 1850. 
 
 26. Bollinger: Ziemssen's Cyclopedia of Practice of Medicine, 
 iii., page 521. 
 
 27. Robinson; Br. Med. Jour., 1884, i., page 570. 
 
 28. \\'eigel u. Noack: Jahrsbericht der Ges. Med., 1890, page 
 ' 642. 
 
 29. Schafferu. Esser: F'ortschritte der Med., 1884, page 40^- 
 
 30. Esser u. Schiitz: Fortschritte der Med., 1885, page 301. 
 
 31. Weissenberg: Allg. med. Central-Zeitung, 1890, page :. 
 
 32. Gaffky; Deut. med. Woch., 1892, xviii., page 14. 
 
 33. Niven: Br. Med. Jour., 1895, ii., page 1,073. 
 
 34. Rep. Mass. Board of Health, 1892, page 667. 
 
 35. See tables for references to tabulated epidemics. 
 
 36. Basenau: Arch. f. Hygiene, xxiii., page 170. 
 
34 
 
 37- Gaffky; On Cholera in Egypt and India, Berl., 1887, 
 page 226. 
 
 38. Simpson; Practitioner, 1887, xxxix., pages 144-156. 
 
 3g. Newton and Wallace; Rep. of N. J. Board of Health, 1885, 
 1886, page 318. 
 
 40. Firth: Practitioner, 1887, xxxix., page 75. 
 
 20s West Fifty-Seventh Street. 
 
Dangers of the Domestic Use, Other 
 Than Driqking, of Contami- 
 nated Water, 
 
 WITH SPECIAL REFERENCE TO MILK AND OYSTERS 
 AS CARRIERS OF BACTERIA. 
 
 By ROWLAND GODFREY FRBBMAH, M. D., 
 
 Fatholocrist to the Foundling Hospital; Pathologist to St. Mary's 
 Free Hospital for Childreo, New York. 
 
 Reprinted from the Albany Medical Ahmals, Volume xviii, 
 ■ Numbers 3 and 4, March and April, 1897. 
 
IV. DANGERS OF THE DOMESTIC USE, OTHER THAN 
 DRINKING, OF CONTAMINATED WATER, 
 
 WITH SPECIAL REFERENCE TO MILK AND OYSTERS AS CARRIERS OF BACTERIA. 
 
 BY ROWLAND GODFREY FREEMAN, M.D., 
 
 Pathologist to the Foundling Hospital ; Pathologist to St. Mary's Free Hospital for Chil- 
 dren, New Yorlf. 
 
 Water containing pathogenic bacteria may cause disease in many 
 ways other than by being used for drinking purposes, these depend- 
 ing, for the most part, on an intermediate contamination of some 
 article of food which is eaten uncooked. 
 
 Of the articles of food which carry the bacteria from contami- 
 nated water, those which are themselves good media for the growth 
 of most bacteria, as, for example, milk, are by far the most danger- 
 ous, for simply washing milk pails with water containing the bacilli of 
 typhoid fever may introduce the germs into the milk in which they 
 can rapidly increase. Such seemed to be the mode of contamina- 
 tion of the milk in the recent very severe epidemic of typhoid fever 
 at Stamford,' Connecticut. 
 
 There are other articles of food which will carry the living bac- 
 teria, but will not furnish a favorable soil for their multiplication 
 such as oysters and ice cream. Butter, clams, salads and fruits may 
 probably act as the carriers of pathogenic bacteria, but concerning 
 their efficiency in this capacity we have as yet little definite 
 knowledge. 
 
 Milk. — Milk, providing as it does, a favorable medium for the 
 growth of most bacteria, has probably conveyed more disease from 
 contaminated water than any other article of food. Cholera, diph- 
 theria and typhoid fever have all been transmitted in this way. 
 
 The usual explanation of this conveyance of bacteria is that the 
 pails were washed in the contaminated water, and in one epidemic at 
 least, already quoted, that appeared to be the real explanation. In 
 other cases the water gets into the milk during cooling, while in still 
 others the water is used to increase the bulk of the milk. 
 
 Cholera. — The conveyance of the bacillus of cholera from con- 
 taminated water was well demonstrated in an epidemic on shipboard 
 reported by Simpson.''' Of the ten sailors who drank the contami- 
 nated milk all had cholera, while of the remaining fourteen members 
 of the crew only one had cholera. The milk was furnished by a 
 
man who washed the clothing of the crew. He admitted having 
 mixed the milk with a fourth part water from a tank, the water of 
 which had caused an epidemic of cholera in the neighborhood. 
 
 Diphtheria. — Out of eleven epidemics of diphtheria which I have 
 collected^ and which were caused by milk, in two, Henden* and 
 Cardiff,'^ the milk was supposed to have been contaminated by the 
 well water used at the farms, which was found to contain sewage. 
 At Cardiff the epidemic was stopped by closing the well. 
 
 Typhoid Fever. — Typhoid fever has been shown to have been trans- 
 mitted by milk in many epidemics and in some of these contami- 
 nated water has been the source of the trouble. Of fifty-three 
 epidemics of typhoid fever due to milk" in nine the contamination 
 originated from foul water. 
 
 An epidemic of typhoid fever, due to the contamination of milk by 
 the contaminated water of a stream, occurred in Geneva, Switzerland, 
 in 1890.'. A number of cases of typhoid fever occurred among the 
 consumers of one milk supply. No case of typhoid fever was found 
 in the family of the milkman or dairyman. The dairyman, however, 
 washed his pails in a stream in which a neighbor was washing the 
 clothes of a typhoid fever patient. So strong was the evidence 
 against this dairyman that the milkman sued him for damages and 
 recovered fifteen hundred francs. 
 
 A still more interesting epidemic of typhoid fever illustrating the 
 way contaminated water may enter milk during cooling occurred in 
 Springfield, Mass., in 1892.° In this town of forty-seven thousand 
 inhabitants there were one hundred and fifty cases with twenty-five 
 deaths : one hundred and one had milk from the same dairy and 
 one hundred and thirty-five may have had some of the milk. This 
 milkman received his milk from several farms, and on that account 
 there was considerable delay in ascertaining the source of the con- 
 tamination, for the milkman did not encourage investigation at the 
 farm on which the contamination took place. Here the farmer's 
 daughter was found to be suffering from typhoid fever. The privy 
 contents were emptied on a field through which the laborer's walked. 
 The milk cans were cooled by submerging them in a well after first 
 plugging them with wooden stoppers. The morning's milk remained 
 submerged in this well all day. The well was covered with planks 
 on which were masses of manure. The plugs in four out of nine cans 
 examined were found to leak. On bacteriological examination this 
 water was found to contain colon bacilli, thus giving evidence of fecal 
 
contamination. Other epidemics where milk has apparently served 
 as the carrier of the Bacillus typhosis from contaminated water are 
 those at Warwickshire in 1883," Gronigen in 1885,'° Shoreham in 
 1886," Minnegue in 1887," Leeds in i892,'-' Brixton in 1894" and 
 South Lambeth in 1894." 
 
 Oysters. — Besides milk the other article of food which has been 
 demonstrated to be an important conveyer of pathogenic bacteria 
 from contaminated water to the human body is the oyster. This 
 property is probably shared by other shell fish although it is only in 
 the case of the oyster that the facts have been thoroughly demon- 
 strated. 
 
 Typhoid Fever. — To Dr. W. H. Conn, of the Wesleyan University, 
 belongs the credit of having established this fact, and with the publica- 
 tion of his article" in December, 1894, practically begins the literature 
 on this subject. In the autumn of 1894 an epidemic of typhoid fever 
 broke out among the students at Wesleyan University. Twenty-six 
 cases appeared between October 20th and November 9th. Of these 
 twenty-three were pronounced, thirteen were very serious and there 
 were four deaths. After a long series of investigations and the 
 exclusion, one after another, of suspected causes of the epidemic the 
 following facts were conspicuous : all those attacked were men, all 
 students of Wesleyan University, and all but three were members of 
 three out of seven college fraternities. Of these three college fra- 
 ternities twenty-five per cent, of the members were attacked. With 
 these data he searched for some common cause of infection one or 
 two weeks previous to the outbreak of the epidemic. He found that 
 on October 12th, eight days before the occurrence of the first case, all 
 the fraternities had their annual initiation, followed by a supper. 
 All the articles of food used at these suppers had come from different 
 sources with the single exception of the oysters, all the three fraterni- 
 ties affected being supplied by one dealer, while none of the other 
 four ate these oysters. The oysters were eaten raw. It was found 
 that two of the three cases occurring in men not members of these 
 fraternities had eaten oysters from the same supply. Of twenty 
 alumni who attended these suppers, two suffered from typhoid fever, 
 and of five Yale students who attended two were taken with typhoid 
 fever four weeks later. Having ascertained that the oysters were the 
 carriers of the infection, he turned his attention to ascertaining the 
 cause of the contamination of the oysters. He found that the oysters 
 were grown in 'Long Island sound and were freshened in a creek 
 
about 300 feet from the outlet of a private sewer from a house where 
 there were two cases of typhoid fever. Conn thus demonstrated 
 that the disease, with one possible exception, occurred only in con- 
 sumers of these oysters, that these oysters were the only common 
 article of food, and that the oysters were fattened in a place where 
 they were liable to contamination by sewage from typhoid patients. 
 It remained to be demonstrated that typhoid bacilli could find 
 a habitat in the oyster and could live there long enough to be active 
 at the time the oyster was used as food. It had already been shown 
 bydeFreytag" that the Bacillus typhosis could live in a concen- 
 trated salt solution for five months, and by de Giaxa " that it could 
 live in unsterilized sea water nine days and in sterilized sea water 
 twenty-five days. Foote," of New Haven, by a series of laboratory 
 experiments, ascertained the following facts : 
 
 1. The Bacillus typhosis will live at least eight days in water taken 
 from an oyster bed. 
 
 2. Oyster juice contains a varying number of bacteria, but fewer 
 than occur in the water in which the oysters live. 
 
 3. The Bacillus typhosis injected into oysters will remain abundant 
 for two weeks, after which period the number present is diminished, 
 but they can be found thirty days after injection. The Bacillus 
 typhosis will live longer in oyster juice than in water. It has more 
 recently been shown by Herdman and Boyce ''° that oysters can live 
 for a prolonged period in water rendered opaque by sewage, and 
 can to a certain point render clear water containing sewage. 
 They find an enormous increase in the bacterial contents of oysters 
 brought from the sea and freshened near a drain pipe, the number 
 increasing from 10 to 17,000 in one case. They also find that the 
 Bacillus typhosis will live in oysters fourteen days. 
 
 Enteritis and Typhoid Fever. — Soon after the publication of Conn's 
 paper reports of suspicious cases of oyster typhoid and enteritis were 
 frequent. Sir William Broadbent" related six separate cases he had 
 seen in consultation in which he attributed the typhoid fever to the 
 eating of raw oysters. 
 
 Dr. Johnson-Lavis " called attention to the large number of cases 
 of gastro-enteritis following the eating in Naples of oysters which had 
 been freshened in the foul waters of Santa Lucia. Grant''' wrote of 
 four men who ate oysters together on the evening of Nov, 5th, of 
 whom, on the 23d, three were sick with typhoid fever. Dr. W. 
 Wilson" of Florence, Italy, reports several cases in- which the evi- 
 dence against the oysters is strong. 
 
An interesting' case is reported by FitzGibbon" in which an in- 
 fection with typhoid fever is attributed to oysters. These oysters 
 were brought direct from the sea and were not fattened. They had, 
 however, been stored in a house where there was a case of typhoid 
 fever. Blyth^° writes of a dinner party of six people, all of whom 
 ate raw oysters ; all were attacked with severe diarrhoea and other 
 symptoms of gastro-enteritis and one subsequently developed typhoid 
 fever. 
 
 An outbreak of disease following the ingestion of raw oysters 
 occurred, as reported by Chantemesse/' at I'Herault, France, last 
 February. This town had been free from typhoid fever for about 
 a year. On February 15th a basket of oysters from Cette was sold 
 and eaten raw by fourteen persons, all of whom were afterward ill, 
 eight with slight diarrhcea, vomiting and malaise, four with putrid 
 dysenteric stool and two with severe typhoid. Others in the same 
 houses who ate no oysters remained well. 
 
 An important recent paper on this subject is that of Arthur 
 Newsholme," the Medical Officer of Brighton, England. Of 181 
 cases of typhoid fever occurring at Brighton during the years 1893- 
 1896, inclusive, 56, or about 31^, were attributed to shell fish, and 
 of these 36 were attributed to oysters and 20 to other shell fish. 
 Nearly all these shell fish were traced to one source, and at this 
 place the oysterS lay between high and low tide in mud which showed 
 evidence of sewage. Sewers discharging near the beds of both the 
 oysters and mussels contained the sewage of several thousand 
 persons. 
 
 Cholera. — That oysters may have played some part in the extension 
 of the epidemic of cholera in England in 1893 is suggested by the report 
 of the Medical Officer of the Local Government Board. °° The evi- 
 dence, however, is circumstantial and not convincing. Grimsby 
 and Cleethropes, two watering places at the mouth of the Humber, 
 are at the apex of a triangle which includes thirty-four of the fifty 
 places attacked. Two hundred and thirty-five thousand excursion- 
 ists visited these places during the two months that cholera pre- 
 vailed. These places distributed four hundred thousand oysters a 
 week. The oyster beds are periodically bathed in sewage. 
 
 On the other hand, it has been found by Frankland " that cholera 
 bacilli if introduced into oysters usually disappear in six hours. In 
 two C4ses they were present in 24 hours. In no case in 48 hours. 
 
 The recent publication of the Local Government Board of England 
 
6 
 
 on oyster culture in relation to disease " shows by a series of excel- 
 lent maps the danger of many of the oyster beds of the English coast 
 from sewer contamination. 
 
 Conclusion. 
 
 1. Most articles of food which are eaten raw and are liable to be 
 washed with contaminated water may be carriers of pathogenic 
 bacteria. 
 
 2. Milk, being a good culture medium for most bacteria, is a 
 most dangerous article of food when taken raw if it has been con- 
 taminated by foul water, as proved by many epidemics. 
 
 3. Oysters are very liable to contamination if freshened near the 
 opening of sewers. Oysters which have become contaminated have, 
 when eaten raw, caused gastro-enteritis in some cases and in others 
 typhoid fever. The Bacillus typhosis is viable in oysters from four- 
 teen to thirty days, while the Bacillus cholerse will live usually but a 
 few hours. 
 
 BlBLIOGRAPHV. 
 
 I Smith. Report on the Stamford Typhoid Fever Epidemic. 
 ■£. Simpsoa Practitioner, XXXIX, p. 144. 
 
 3. Freeman. Med. Record, March z8, i8g6. 
 
 4. Power. Lancet, '83, II, p. 145. 
 
 5. Paine. Br. Med. Jr., '83, I, p. 873. 
 
 6. Freeman Med. Record, March 28, 1896. 
 
 7. Vincent. Lancet, '90, II, p. 730; Br. Med. Jr., ^92, I, p. 1279. 
 
 8. Sedgwick. Bost. Med. and Sur^. Jr., ^93, II, p. 489. 
 g. Vi'ilson. Br. Med. Jr. '83, I, p, 1136. 
 
 10. Ali Cohen. Schmidt's Jahrb. CCXX, p'. 197. 
 
 11. Kelly. Practitioner, '86, XXXVII, p. 223. 
 
 12. Janssen Rouvier, Le r.ait,.p. 208. ' 
 
 13. Kallard-Arnley. Stevenson & Murphy^ Hygiene, I, p. 334. 
 14 Verdon. Br. Med. Jr., '94, 1, p. 1112. \ 
 
 15. Verdon. Br. Med. Jr., '94, I, p. 1149. ' 
 
 16. Conn. Med. Record, '94, II, p. 743. 
 
 17. de Freytag. Arch. f. Hyg., 'go, XI, T, p. 60. 
 
 18. deGiaxa. Zeitschf. Hyg., '89, Bd, VI, p. 162. 
 
 19. Foote. Med. News, '95, 1, p. 320. 
 
 20. Herdman and Boyce. Br. Med. Jr., '95, II, p. 724. 
 21 Broadbent. Br. Med. Jr., '95, II,p. 61. 
 
 22. Johnson-Lavis. Br. Med. Jr., '95, I, p. 559. 
 
 23 Grant. Br. Med. Jr., '95, 1, p. 171. 
 
 24. Wilson. Br. Med. Jr., '95, 1, p. 391. 
 
 25. FitzGibbon. Br. Med. Jr., 'g6, II, p, 1687. 
 
 26. Blyth. Br. Med. Jr., 'g6, II, p. 1843. 
 
 27. Chantemesse. , Br. Med. Jr., '96, I, p. g7. 
 
 28. Newsholme. Br. Med. Jr., '96, II, p. 639. 
 
 29. Report, etc. Br. Med. Jr., '95, I, p. 881. 
 
 30. Frankland. Lancet, '95, I, p. 62g, 
 
 51 . Supplement of 24th Annual Report of the Local Government Board on Oyster Culture in 
 Relation to Disease. 
 205 West 57TH Street. 
 
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