routine to be explained-who pays the fiddler? Our schedule allows the bacteriologist and chemist $5 for every examination; our veterinarian $10 for each inspection. These items, along with that of printing, supply of caps and seals, etc., are met by the dairymen in the following manner: The dairyman pays a tax of one half cent per pint of certified milk produced; pays a tax of half a cent per quart of "inspected milk" produced. It is a little early to predict the ultimate result, but we are at the present output assured of sufficient income to allow of the frequent examination of their product. The Milk Commission adopted this per bottle tax on the basis that it would then be enabled to take care of the small producer by making the larger producer help pay the expenses of inspection, etc., of the small producer. I will explain that the minimum expense of the Commission on each dairy, with but one series of reports from experts, would be $20.00 per month, exclusive of the cost of caps and seals for each. Under any other scheme a dairyman would have to have a production of fifty gallons of milk a day before the Commission could afford to enter into agreement to certify to this milk.

I will digress for a moment to say a word in the way of our finances. The Treasurer showed that there was a fund of $820.50 created by our circularization. We call this our Milk Campaign Fund. It was necessary in the preliminary work to call heavily upon this fund. We propose as time goes on and the consumption increases to return a certain amount of our income, above expense of overseeing the dairies under our control, to this Campaign Fund, and thereafter charge all of our preliminary, prospective and experimental work to this Campaign Fund. Nothing will so much induce public confidence as to be able to show a definite financial programme along with our scientific efforts.

This simple recital of the doings of the Milk Commission is not offered as anything of scientific value, but is rather an attempt to exchange places with you for one evening, for we feel assured that with a closer knowledge of this subject will come enthusiasm on your part as well, and then our share of the work will become comparatively light.

In its efforts thus far the Milk Commis

sion has probably met the purposes for which it was originally appointed by the Academy-that is, to supervise the production of a limited supply of milk, of whose quality the physician could at all times be certain, and which he could prescribe unhesitatingly to infants, invalids and convalescents. The Commission feels, however, that a much larger field is before it, and that it will not be satisfied until it has stimulated the production, under ideal conditions, of a much greater supply of clean milk; until it has secured for all hospitals and institutions the use of a guaranteed milk; until it has stirred the public interest and charitably inclined citizens to such a degree that the use of pure milk will become possible to the very poor in the tenement districts. Mr. Nathan Strauss, of New York, has shown what is possible in this direction. He is building one laboratory in New York for the modification and bottling of pure milk, and it is calculated that this institution will save the lives of 10,000 infants annually in New York City.

St. Louis, through her milk commission, is expending about $5,000 annually in supplying a safe milk to the poor and needy. Boston has its municipal milk depot, as has Cambridge. Chicago, through its milk commission, is distributing thousands of bottles of milk, and so it is not difficult to see the opportunities that present themselves to such a commission.

Here in Cincinnati the dairy conditions are particularly vicious, and a survey of the field leads to the belief that eventually many, if not all, of these small dairies will have to disappear, and that in the place of small, filthy, slop-fed dairies there will come large dairy farms, under the control of men of means and intelligence, who, under ideal conditions, will produce milk at advanced prices, being satisfied with fair dividends on their investment.

Your Commission feels keenly the lack of co-operation it has found on the part of the profession in its efforts to introduce the use of inspected milk in hospitals. Such assistance as we have received has been almost, as it were, at the point of the bayonet. Early in our campaign the plan was conceived of getting dairymen to supply a guaranteed milk in bulk to hospitals. It was no easy task to make up a list of dairymen who might be con

sidered promising prospects. Our next plan was to visit their farms; our purpose we then laid before them.

They were to conform to all requirements of the Commission for inspected milk and ship their product direct to the hospitals in ten-gallon cans. We had learned that it was possible to buy cans covered with felting, which are made for the shipment of milk that had been reduced to low temperature. It is claimed that the temperature of the milk shipped in these cans would not rise over one degree per hour. With the short railroad hauls

a product for the use of your patients, and if you are not willing to go before your boards and demand the same, then we as a Commission must cease our efforts in this direction, lest there be some misconception of our motives on the part of those in control of such institutions, whose knowledge of things of this sort cannot of necessity be any greater than that of those who are supposed to advise them in all things medical. You would resent their interference in your methods of conducting the operating-room and yet you will allow the feeding of milk, whose very

Signed

milk cream

reaching the Bacteriological Standard

about Cincinnati it would be possible for dairymen to cool milk to 40° or lower and have this reach the hospital under 45° F. We were successful in finding a number of dairymen who desired to co-operate with us, and who stated that they would attempt it if they were assured of a market for their product at twenty cents a gallon net.

A conference with the express company brought the information that it would cost about three cents additional to ship same. This included the return of empty

cans.

We felt sure that at this price, twentythree cents, we would not have any difficulty in placing such a product. So confident were we in our belief that one of the dairymen proceeded to equip his plant. Three months have elapsed, and we are ashamed to admit that not one pint of this milk have we been able to place. The responsibility now lies with you, members of this Academy, connected with hos pitals. If you do not see the value of such

Bacteriologist.

quality is a menace to the already enfeebled patient. Let us as physicians have a care lest the laity show more wisdom than we in these things.

A woman was complaining on one occasion to Dr. Osler that Providence had seen fit to take her little child, when Dr. Osler interrupted with this remark: "Providence had nothing to do with it; it was dirty milk." Providence had nothing to do with the recent epidemic of diphtheria in Clifton. It was rather the present indifference to facts and conditions which make such things possible to-day. This epidemic has had some virtue if it will teach us as physicians to inquire more closely as to the source of supply when we order milk for our patients.

Before closing, I desire to say a few words regarding the status of other commissions. It would, indeed, be foolhardy for me to try to tell this Academy their history since the initial organization at Newark, N. J., in 1893. Dr. Coit is re

sponsible for the coining of the word "certified," as applied to milk. He had it copyrighted in the name of Stepen Francisco, their dairyman, with the stipulation that all milk commissions of the country were to be entitled to its use.

It may not be amiss here to state that one dairyman in this city is using the term "certified on a product which we know is far from the standards adopted by this Commission.

In the latter part of July a serial of twenty-five questions concerning the vital points of organization, etc., was sent to all commissions of which we then had knowledge. I have attempted an almost impossible task in tabulating their replies,

a conference of all the milk commissions of the country. An invitation for such a conference has been sent out by our Commission, and it is probable that the conference will be held in June.

This would do much toward standardizing our individual standards, make for greater effectiveness all along the line, and call for a clearer understanding of our aims by the entire profession.

It has been suggested that milk commissions and their results are akin to class legislation, in that they cater to the favored few, and that the health departments in the various cities should be so effective that all milk would be of certified standards. We will plead guilty to the

Milk Commission
CERTIFIED

Academy of Medicine

Cincinnati, O.

Date.......

Milk Commission INSPECTED Academy of Medicine Cincinnati, O.

Signed................

at least in part. Out of the mass of correspondence that is on the files comes one fact with great certainty-the work of milk commissions is valuable, not only in that they produce a limited supply of pure milk for a comparatively small number of people, but that they undoubtedly aid largely in raising the standard of the general supply.

One thing which has impressed me in my correspondence with the milk commissions, as much as the tables that have grown out of it, is the genuine spirit of helpfulness and enthusiasm that is shown by those who are directly responsible for this work.

Our review of the work leads to the hope that at a near date there will be held

Secretary.

charge if you will make it read that milk commissions cater to the favored few intelligent ones. It is a known fact in political life that legislation is never beyond the average intelligence of the community for which it is made. You might as well attempt to legislate against groceries keeping different qualities of the same goods as to attempt to enforce all of the people at one full sweep to pay an increase of 25 per cent. or more on the present market price of ordinary milk. We must hope rather by agitation to gradually awaken the appreciation for a cleaner product of uniform fat content; teach the public to buy milk with the same shrewdness and knowledge of its value as they evince in other things.

When you are ready to assist the Milk Commission in the dissemination of such knowledge, when you stand shoulder to shoulder with them in their desire to put a premium on merit, when you likewise do all in your power to strengthen your Health Officer in his efforts to wipe out the worst offenders, then we will have two powerful forces working for the common good-one a constructive force which, by example, shows what may be done under ideal conditions and which places a premium on merit; the other, a force limited in its scope to the power given the Health Officer by law to eradicate the worst evils. When the profession lends its aid to these forces, then indeed may we look for the raising of the standards of the general supply of milk in our city. Preliminary Counts on Certified" by Dr. Hollingshead.

Date Examined. Average. Date Examined.

440,000 July 18, 5,50,000 July 21, 85,000 July 23, 64,000 July 24, 15,000 July 25,

Average.

July 2, 1906

17,500

July 5,

Bacteria per c.c.

July 7,

July 9,

July 11,

55, 228,

7,850,000

July 14,

45.000 July 28,

66

66

23,

154,

July 16,

5,250,000 42,400,000 1,850,000

30,

$8,

1906.

Collected by

Hour. Bact.perc.c.

July 18. Hegner

4. p.m. 17,000

July 23.

66

4. p.m. 4,200

5,

242,

1,450,000 3.400,000 320,000 5,770,000

66

July 30.

46

64

Aug. 9.

Aug. 29.

IO,

177,

1,500,000 I1,900,000 6,480,000

66

Sept. 23.

(wagon)

Sept. 23. Geier, B. M. C.

Oct. 6. Hegner

66

6.00a.m.

2,300

Oct. 24.

8.30a.m.

2,200

Oct. 30.

46

Oct. 30.

66

Bacterial Counts Made on City Milk by Dr. Samson, City Chemist.

Bacteria per c.c. 8,896,436

Nov. 16.

3.00 p.m.

7,300

66

463, wagon 525, store 526, wagon

257,000 2,090,000 1,800,000

634, 4,080,000 635, store 1,800,000

Some Bacterial Counts Made by Dr. Samson, City Chemist, to Show the Relative Growth of Bacteria in Two Specimens of the same Milk, One Iced, the Other Uncooled:

SAMPLE NO. I KEPT AT 12 DEGREES C.

Aug. 10, 11.25 A.M.

8.00 a.m. 25.300 11.00 a.m. 11,000 6.00 p.m. 34,000 3.00 p.m. 10,500

Bacteria per c.c.

11,300

28,000

32,000

70,000

2,150,000

Oct. 30. 66 (Hand)
Oct. 30. 66
Nov. 16.

64

(Milk Machine) 3 00 p.m. 1,300 (Hand) 3.00 pm.375,000 9.00 a.m. 98,000 .11.00a.m. 29,000 II 30 a.m. 11,200 9.00 a.m. 36,000 m. 4,050

Dec. 20.

Dec. 10. 66

46

Dec. 23. 66

66

Jan. 21, '07"

66

.12

THE CINCINNATI HOSPITAL SITUATION. CINCINNATI, March 9, 1907.

EDITOR LANCET-CLINIC :

Would you allow me a little space to clear up some misapprehensions that evidently exist in the minds of the writers on "The Cincinnati Hospital Situation" in your issues of February 23 and March 2?

Dr. Minor says: "To our mind the locality chosen for contagious disease branches of such a municipal institution was ill-advised and a sanitary mistake of a most serious character. . . . Sanitarians have ever insisted that contagious disease hospitals should be completely isolated from large centres of population," and the context shows that the doctor thinks that the "contagious disease branch" of the new hospital will include a smallpox hospital or pest-house. This is not the case. The smallpox hospital, or Branch Hospital Annex, as it is known, is to remain where it now is on Lick Run. There has never been the slightest intention of removing it to the Avondale site, for the very good reason that it is obviously where it ought to be beyond the city limits. The new contagious diseases department of the hospital is for cases of diphtheria, scarlet fever and measles. The experience of other large cities, such as Boston, New York and Philadelphia, shows that the immediate vicinity of the main hospital is the place for the branch for the contagious diseases of children, and as the entire new hospital will be built on the new site in a few years' time, it is proper that the contagious diseases department should be placed just where it will be built this spring and summer. As for the danger of contagion in the surrounding residence district, that danger does not exist! A careful examination of residence districts of other cities lying contiguous to 'hospitals for the contagious diseases of children has failed to discover a greater number of these cases than exist in similar residence districts lying remote from the hospitals. This argument was effectually disposed of by Dr. Dandridge in his address to the Board of Public Service in reply to this objection by Mr. Bender,

and in support of his contention he cited the experience of Boston, where the contagious-diseases pavilions are in the immediate vicinity of the Boston City Hospital. As for placing the hospital for the contagious diseases of children at "some remote point in the southwestern corner of Hamilton County," the obvious reply is that, in the first place, it is unnecessary; and, in the second place, if the hospital were placed there it would remain permanently empty. The hospitals for consumption and for smallpox on Lick Run, although not in the southwestern corner of the county, are certainly sufficiently remote from the habitations of men at present, and likely to remain so for many years.

Dr. Minor also says: "Modern sanitarians favor cheap and easily replaced buildings for cases of this kind, buildings that should be burned down every seven or eight years." That idea of temporary pavilions that should be burned after eight or ten years' service prevailed before the modern era of cleanliness and asepsis. It was a doctrine of despair that perished with the advent of Listerism. Fifteen years ago Cowles wrote of the "temporary pavilions" that had been built for the Boston City Hospital for a ten years' service.

When the appointed hour came that they should be burned they were doing such good service that by a few strokes of carpenter and plasterer and painter they were turned into permanent buildings, and Boston planned no more "temporary pavilions." Modern improvements in flooring material, in densely hard, non-absorbent wall and ceiling material, and in the mechanical arrangements preventing the accumulation of or instantly removing all dirt, non-infectious or infectious, enable us at the present day to build with confidence hospitals intended to stand and expected to do good service for a century.

As for the cases of consumption that apply for admission to the present old hospital, it is perhaps true that we do not arrest them, as Dr. Minor says they were arrested in sixteenth-century Italy, but we certainly do put them in the police ward