EXPLANATION OF DIAGRAM IV. Each red dot represents a case of typhoid fever. A-Farm where original case occurred in September and was nursed by wife of farmer B. B-Dairy farm where wife nursed preceding case and prepared the milk for market. She and one son were ailing for some days but did not stop work until October 8. The dash-lines represent the course and distribution of the milk from farm B. All the cases of typhoid were on this milk route. C and D were farms selling milk to farmer B. No typhoid occurred on these 2 farms. E-Farm receiving a small amount of milk daily from B for use of girl staying at farm. This girl contracted typhoid. F, G, and H-The 3 other dairy farms supplying milk to Elkton. The solid lines represent their routes. No case of typhoid on these routes. The milker's hands may have become soiled in acting as nurse for some case of typhoid in the family. He may be a convalescent from scarlet fever and be shedding particles of epidermis into the milk, or he may have diphtheria, or possibly tuberculosis, and with every act of sneezing and coughing spray tubercle or Klebs-Löffler bacilli with particles of sputum. If he does, as is not entirely unknown among careless milkers, and moistens his hands by spitting into the palms to facilitate the action of the fingers upon the teats, it is easily seen how infective material may find its way into the milk. (2) Air and dust of the stable. The stable dust may contain organisms eliminated by those working in it, and as some of this dust and other stable refuse adhering to the flanks, buttocks, and udders of the cows and floating in the air finds its way into the milk, under the conditions sometimes employed, it may carry with it these organisms. (3) The milk pail.-The milk pail may have been washed and taken care of by some person or member of the family suffering from a contagious or infectious disease and in the handling have received its quota of typhoid or other bacilli which thus find their way into the milk. (4) Water supply. The water supply of the farm or dairy may be at fault. Farms are often very unfortunate in the location of their wells, which very frequently become polluted by cases of typhoid on the premises. The privy vaults are at times not far distant and are apt to be leaky and subject to seepage, and when a case of typhoid fever occurs on the place or a person eliminating the bacilli sojourns temporarily on the premises, the possibility of water contamination exists. In some cases the dejecta of typhoid patients are buried in shallow holes around the house and often unwittingly around the well, while at other times, as occurred in some of the epidemics reported later, the dejecta were simply thrown on the ground where they could easily find their way into the water supply. Pails washed in polluted water, if not afterwards scalded, may contain the infective material and the more so if some of the last rinsing water still remains in them. The possibility of this water being added directly to the milk need not be considered, although it has undoubtedly played an important part in some epidemics. The water used may be a stream into which some household higher up empties its sewage. It has been supposed that cows wading into polluted streams might get upon the udders contaminated water, which in the act of milking would find its way into the pail. This at least is one of the rarer means of infecting milk. (5) Milk cooler.—If a milk cooler is used and not properly taken care of infectious material may reach the milk through it. (6) Cans. If the milk is then put into cans the same possibilities are again met as in the pails. (7) Transportation. If the milk is now shipped to a distributing dairy in the city there is always the possibility of its infection in transit by those handling it, and it must always be borne in mind that some person may surreptitiously dip into the container with a soiled vessel or dipper or even drink from the mouth or top of the can. (8) Distributing dairy.-Then there are the receptacles used by the retailer. In many distributing dairies the milk comes in by train in large cans, and before the contents are poured together in the mixer each can of milk must be tasted to ascertain whether or not it is sour. One man usually does the tasting. It may be done in a manner free from criticism or the taster may tip each can before it is lifted from the wagon and, removing the top, place his mouth to the can and taste the milk. When milk has been treated in this manner it has at times been the custom to draw into the mouth a sufficient amount and then spit it upon the ground. One taster has been mentioned who was so economical that he returned the tasted milk to the can. Another means of tasting which has at times been employed is to use a spoon or small dipper, inserting it into one can after another, and of course between cans into the mouth of the taster. A method less subject to criticism is to tip each can, then removing the cap, taste of the milk adhering to it. The top can then be cast aside and scalded before further use and the milk emptied into the mixing tank. Other methods entirely free from criticism are commonly used by careful dairies. (9) Bottles. It is at present the custom to deliver milk to the consumer in bottles. This is especially so in the cities. It can be seen how this practice properly operated may be better than any other; but, on the other hand, if carelessly conducted may be a source of much danger. Clean milk in sterile well-capped bottles, handled and delivered by clean men, free from disease, is a condition much to be desired. But where empty bottles returned from the consumers' houses are not properly scalded before being again filled, the possibility of contamination by pathogenic organisms is necessarily considerable. Bottles left at houses where there are cases of scarlet fever, typhoid, or diphtheria, if refilled without being properly scalded, are undoubtedly a source of much danger. Many cities have ordinances to prevent this, but the constant presence of mild cases of disease, so mild and, according to present standards, atypical, that a correct diagnosis is not made, renders all regulating measures more or less ineffective. The accidental infection of bottles in an orderly well-regulated household need not be considered so long as certain classes of people persist in using them for various other purposes such as urinals and receptacles for sputum. Dr. Herbert Fox, chief of the laboratories of the Pennsylvania State department of health states: The attention of the commissioner of health, Dr. Samuel G. Dixon, was called to a slimy mass of material on the under surface of a milk-bottle cap. He sent this to the laboratory and it was received in a very dry condition. Upon softening down and smears made from it we were able to obtain sufficient proof that it was sputum. Doctor Dixon informs me that he has known of milk bottles used for cuspidors on more than one occasion. The practice of drinking directly from the bottles is a habit that must also be borne in mind as a possible means of contamination with tubercle and Klebs-Löffler bacilli. An example of apparent bottle infection is found in the typhoid outbreak at Montclair, N. J., in 1902. Montclair epidemic.-During the summer and autumn of 1902 there was only an occasional case of typhoid in Montclair. The 1st of December several cases occurred, apparently having milk from one dairy as the only factor in common. Investigation of the farms producing this milk failed to reveal any cases of disease which could be the source of the infection. All persons coming in contact with the milk were apparently in good health. More careful examination of the invaded houses showed that cases of typhoid existed only in those houses receiving milk in pint bottles. There were no cases among the quart-bottle customers. Cases continued to be reported on this route and the sale of milk from the dairy was therefore stopped. After two weeks new cases ceased to develop. It was then found that a man from New York City had come to Montclair ill with typhoid fever and had remained for a few days at a house supplied with milk from this dairy until he could be remoyed to a hospital. This house had during the patient's stay been supplied daily with 3 pint bottles of milk. The empty bottles were removed daily and, without sterilization, refilled and delivered to other houses. It seemed that this was the means of spreading the disease. Eighteen cases occurred in Montclair and 10 in Bloomfield, all in houses supplied with milk in pint bottles from this dairy. Pathogenic organisms may possibly reach the milk through dust while in the care of the vendor, but most likely the vendor himself is the more important and that, while organisms floating in the air can undoubtedly settle into milk, yet the chief danger is from contact with diseased persons or those having an intimate relation with the sick. @Ninth Annual Report, Board of Health, Town of Montclair, N. J., 1903. |