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mals have come under the eye of the bureau: 135,317 cattle, 942,659 hogs,
359,095 sheep, 115,377 calves. Of these there were rejected: 1,534 cattle
(more than 50 per cent for tuberculosis, more than 25 per cent for actinomy-
cosis), 471 hogs (nearly 60 per cent for cholera, none for tuberculosis), 359
sheep (emaciation and crippling the most prominent causes, actual disease
about 10 per cent), 308 calves (immaturity, emaciation and crippling the most
common causes, actual disease less than 15 per cent — 3 per cent for tuber-
culosis).

Meat animals inspected after slaughter: 27,881 cattle, 35,303 hogs,
48,294 sheep, 54,465 calves. Rejections: 143 cattle (more than 67 per cent
for tuberculosis), 249 hogs (83 per cent for cholera, 6 per cent for tubercu-
losis), 203 sheep, 58 calves. In addition to the entire animals condemned
before and after slaughter, parts of 2,029 cattle, 2,607 hogs, 1,603 sheep and
142 calves were rejected at the slaughter houses.

The market and commission house confiscation of meat totaled 63,822
pounds. There are approximately 1,150 meat markets in Cleveland. 598
complaints in regard to meat markets were investigated and a total of 7,308
visits to markets made. There are 190 poultry dressing rooms, to which
1,100 visits were made.

At all slaughter houses and most meat markets sausage is made. There
are eight, or fewer, factories making sausages exclusively. The visits to
sausage factories totaled 501.

Arrests for violating the meat ordinance during the year were 8, arrests for
violations of the milk and bottle ordinance 4, summons to prosecutor's office
5. The number who were brought to trial and who were convicted is not
stated.

The control of rabies is handled jointly with the Bureau of Communicable
Disease but chiefly by the Bureau of Milk and Dairy Inspection. Of 1,000
dogs which were reported in 1919 to have bitten one or more human beings
in Cleveland, 110 dogs were actually rabid, as shown by observation, or the
finding of Negri bodies, or by both observation and examination. 196 per-



150 Hospital and Health Survey

sons were bitten by these dogs and received Pasteur treatment. 39 examina-
tions were made in the laboratory and of these examinations 17, or 43.5 per
cent of the total, were positive for rabies. The history of some of the re-
maining 22 dogs was so suggestive of rabies that treatment was given to the
persons bitten.

Forty-three dogs not found, either dead or alive, were considered rabid on
their history and the 74 persons bitten by them were treated. In addition
to the dogs, four cats were found to be rabid on examination and one was
considered to be so on the history. 14 persons were bitten by these cats,
12 by those with known rabies. One rabid horse bit one person, and rats
were reported as having bitten two people.

If the animal is found alive it is placed under observation; if killed or
found dead, its brain is examined for the presence of Negri bodies. Pasteur
treatment is given on the positive diagnosis of rabies on either of the grounds.
If the animal cannot be found or the presence of Negri bodies cannot be
demonstrated, the circumstances surrounding the biting are considered and
the person bitten is given the benefit of the doubt and Pasteur treatment is
offered.

The quality of supervision of the slaughtering and sale of meat appears
to be excellent, the standards being those of the Federal Bureau of Animal
Industry. All slaughter houses must be under federal or city license and
inspection systems. The regulations as enforced cover all the usual precau-
tions and requirements.

Slaughter house and food factory inspection is made for the non-federal
inspected houses in the city and the 28 outside of the city. About 25 per
cent of the city killed meat is slaughtered in other than federal inspected
houses. No uninspected meat is permitted for sale in the city.

MILK CONTROL

The handling of milk control in Cleveland, in spite of the up-to-date regula-
tions, suffers from several radical defects in principle and method which are
probably responsible for the high percentage of dangerously polluted milk
samples found on the bacterial counts of samples examined at the request of
the Survey by the Bureau of Laboratories in February and June, 1920.

The ordinances do not cover the question of sterilization of containers.
There is dangerous neglect of this important point in the technic of milk
distribution by many dealers. Exclusion of milk supplies is based on the
condition of the dairy, and the results of inspection of the premises where
milk is handled and pasteurized. The routine use of bacterial counts is not
a basis of milk control.

The chief of the bureau agreed that reliance placed upon inspection of
dairies, the amount of dirt by the clarifying test, and the standard method
of pasteurizing and recording by temperature and duration of exposure,
cannot be relied upon to guarantee a safe milk to the consumer as long as
unstcrilized containers are used, which make the milk unreliable even after



Public Health Services 151

pasteurization. Little attention is paid to bacteriological counts for exclu-
sion of milk.

At present, with the apparently limited force, the division could with
advantage gradually change its policy from field inspection to laboratory
control of the delivered milk. Milk inspection is carried out in the country
within a radius of 200 miles and at the pasteurizing plants outside and inside
the city. Chemical tests are made by the inspectors themselves at the
Division of Health laboratory. Bacteriological tests are made by the bac-
teriological laboratory under the director of laboratories.

The following is quoted from field notes made by the investigator for the
Survey on accompanying a dairy inspector on his rounds in the country:

"The inspector stated that he covered his old route once a year and that he tried to
cover new territory more often. During the winter the inspectors do very little work in
the country and in the summer are often called out to do other work. He had 900 dairies
last year under his care and will have about 1,200 this year. When he is on the road he
sees from 10 to 15 dairies a day. Dairies which make butter do not have to come up to
the standard : in fact, he told of several very poor dairies to which he had suggested that
they make butter instead of shipping milk. This is certainly a dangerous policy.

There are no bacteriological tests to determine the cleanliness of utensils. No search
is made for the cause of a high bacteriological count, where the milk is brought in, with a
notice to the inspectors to follow up the high counts.

The score card shows that more emphasis is put on technic than construction. The
inspector observed really seemed interested in the cleanliness of the process, although he
scored dairies without seeing the process of milking or handling of milk. The inspector
was primarily interested in clean utensils and provisions for cooling. The emphasis is
evidently correctly placed. The previous score card is not taken with him when he goes
to make a second inspection. He carries the facts as to previous conditions in his head."

Firmness and an entirely consistent policy of exclusion for specified defects does not
prevail. "Many dairies were using milking machines, which are exceedingly dangerous
unless cared for immaculately. Many of the machines seen were dirty. They cannot be
sterilized. In one dairy an elaborate sterilizing plant was found with all utensils sterilized,
but 12 dirty milking machines."

Tables VII. and VIII. in the Appendix represent the official record of
raw (certified) and pasteurized market milk in Cleveland during the past
six years.

The following reports were received by the Survey from the bacterio-
logical laboratory of the Division of Health :

March 19, 1920

"Enclosed herewith are the results of the bacteriological examinations of the Cleve-
land Milk Supply made recently for the Cleveland Hospital Survey.

"From these we have made the following notations: There were 103 samples ex-
amined. Of those containing 50,000 or less bacteria colonies per c. c. there were 43, or
41.7';. From 51,000 to 100,000, inclusive, there were nine samples, or 8.7%. Of those



152 Hospital and Health Survey



from 100 and 1,000 to 500,000, inclusive, there were 21 samples, or 20.3%. 30 samples,
or 29.1% contained over 500,000 colonies per c.c.

"The presence of gas producers in lactose broth was found in 52 samples, or 50.5%.
Six of these samples showed the presence of gas formers in all five dilutions and one of
these showed the presence in all tests of all dilutions. Five samples showed the presence
of gas formers in four of the five dilutions.

"Of the 92 samples examined in triplicate for the presence of spore forming gas pro-
ducers 36 samples (39%) gave positive results.

Fermentations Spore Formers

Positive Samples Positive Tests Positive Samples Positive Tests

No. Per No. Per No. Per No. Per

Colonies per c.c. Cent Cent Cent Cent

Under 50,000 21 50. 75 11.6 12 23. 24 21.6

51,000 to 100,000 4 44.4 8 6. 3 33.3 4 19.1

100,000 to 500,000 12 57.1 44 14. 5 23.8 9 15.8

Over 500,000 16 53.3 99 22. 12 40. 29 33.3

"The methods pursued in the examination of Cleveland Market Milk for the Hospital
Survey were as follows:

COLLECTION OF SAMPLES

"Samples were collected from the various milk plants, milk wagons and grocery stores
by the writer and other laboratory employes. The milk was brought direct to the labora-
tory in the original package and examined immediately. Owing to the low temperature
of the weather the samples were not iced in transit. Although the temperature was not
taken, it is safe to say that the milk did not reach a temperature of more than three or
four degrees above, and in most cases was several degrees below the temperature at which
it was received, by the time plating was begun. Both quart and pint bottles were collected.

METHODS OF EXAMINATION

"Agar plates were made, using plain standard agar in triplicate dilutions of 1:100
and 1:1000. Fermentations were made in triplicate in lactose broth in quantities of
10 c.c, 1 c.c, 0.1 c.c, 0.01 c.c. and 0.001 c.c. The plates were counted after 24 hours incuba-
tion at 37 degrees C. and the average taken for record. Where the count was high it was
recorded as an estimate; for example, 'Over 500,000.' If fermentation occurred, a trans-
plant was made from the fermentation tube (showing gas) to eosin-methylen blue agar,
the organism isolated in a pure culture for further study. Fermentations incubated for
at least 72 hours.

"Triplicate specimens of 10 c.c of milk each were placed in test tubes with a few drops
of azolitmin solution and heated in the water bath at 80 degrees C. for 30 minutes, and then
incubated at 37 degrees C. for 72 hours or until gas production was indicated. It was then
transplanted to lactose fermentation tubes and reincubated, as a control on the presence
of gas production. These cultures were then plated on plain agar and incubated anaero-
bically for isolation in pure culture for further examination.

"This covers in general the methods of procedure with the Hospital Survey samples.
Some other examinations were originally planned, but either the necessary material and



Public Health Services 153



equipment were not at hand, or other immediate facilities were lacking, so that the work
could not be consistently carried out and was therefore discontinued."

A series of samples examined in June were analyzed in a somewhat
more detailed manner, as shown in the accompanying report from the same
source.

"July 8, 1920.
"Enclosed herewith is a classified report of the bacteriological examination of Cleve-
land market milk.

"Bacteriological Examination — Counts were made in duplicate on plain agar with
dilutions of 1:1000 in sterile tap water incubated at 37 degrees C. for 24 hours. The aver-
age of the duplicates was recorded. Fermentation tests for the presence of gas producers
was made in dilutions of 1:1000, 1:100, 1:10, 1 and 10 c.c, respectively, in triplicates, using
1 % lactose broth Dunham tubes. The figures in the corresponding columns in the report
indicate the number of triplicates showing the presence of gas. Triplicate tests for spore
bearing gas formers were made by placing 10 c.c. of milk in a 6-inch test tube with a couple
of drops of sterile azolitmin solution, and heating in the water bath at 80 degrees C. for at
least 30 minutes. These were then incubated at 37 degrees C. for 72 hours or until gas
formation was indicated, and then transferred to 1% lactose broth in Dunham tubes.
The column "Ana," in the report indicates the number of these showing the presence of gas."

CLASSIFICATION OF DEALERS AND RESULTS

At a conference with the four city dairy inspectors who are familiar with the dairy
premises and personnel, the dealers were placed in three groups:

Group 1 — Dealers whose premises, equipment and methods are of the
best, equipped with bottle sterilizers, coolers, automatic filler and capper, etc.

Group 2 — Those whose methods may be satisfactory but who are not
equipped with the most "up-to-date" apparatus, such as sterilizers, auto-
matic fillers, cappers, etc.

Group 3 — Those whose premises, equipment and methods are the cause
of more or less dissatisfaction.

Classes — The groups are sub-divided into three classes, according to the bacterio-
logical results.

Class A — Contains those whose bacteria count does not exceed 50,000
colonies per c.c. nor have gas formation in more than 50% of the fermenta-
tion tests.

Class B — Includes all that do not belong to Class A, but which do not
have a bacteria count of over 500,000 colonies per c.c.

Class C — Includes all with a bacteria count of over 500,000 colonies
per c.c.

A classification of the patrons is suggested by indicating the so-called better residence
sections by "X," the medium sections by "Y," and the poorer sections, factory districts
and congested portions of the city by "Z."



154 Hospital and Health Survey

In Table IX. will be found the detailed results of this study.

It is easy to see froni the reports that intelligent, consistent, economical
and constructive work through bacterial counts of milk is needed to clean
up the milk supply by tracing the dirty supplies to their source, by testing
the pasteurized product as delivered to the consumer, and then following
back to the production point to discover the place and cause of the con-
tamination.

Among the reasons to which the unsatisfactory condition of the milk
must be attributed are the holding of pasteurized milk without prompt cool-
ing, in the containers used in the process of pasteurizing before bottling;
the use of unsterilized containers for distribution to the consumer; the ab-
sence of any prosecution based on bacteriological tests; and the emphasis
in prosecution of farmers solely upon the sediment test and butter fat con-
tent. The system of milk control does not put any effective check by bac-
teriological methods upon the cleanliness of the milk before pasteurization.
The dealers are prosecuted for failure to meet the requirements in butter fat
and sediment test, for use of bottles not their own, for the condition of their
premises and for the processes used in pasteurizing and bottling. The milk
bottle caps do not show the grade or date or anything except advertising
and trade terms, to indicate the quality and age of the milk. An official
and uniform text on caps would better protect the consumer.

It is recommended that bacterial count control largely replace the present
diffuse and unproductive system of milk and dairy inspection, and that auto-
mobile transportation sufficient to save the time of field inspectors be pro-
vided.

In this bureau, as elsewhere in the Division of Health, we find workers
with sufficient knowledge but hampered by lack of sound policies, and lack-
ing in the educational facilities upon which good preventive health work is
usually done.

The staff meets for conference on Saturday mornings to discuss policies
and the service. There would seem to be no good reason for keeping this
bureau separate from the other food inspection service now carried on under
the city chemist.

The chemical laboratory should not have inspectional functions but should
be used as a source for facts, upon which records, prosecutions and exclusion
of food should be determined.

The personnel of the bureau, except the director, comes from the civil
service eligible lists. Applicants have no medical examination, since they
are not eligible for any pension fund. They are supposed to pass a mental
examination on some of the technical information required in dairy and
meat inspection. This eligible list has been eliminated for the past two
years as there have been no examinations held by the Civil Service Com-
mission. Inspectors are taken as they come, without examination. They
receive for the first year $1,500 salary; for the second year $1,650, and for
the third year $1,800; supervising lay inspector $2,000; the two assistants
$2,400; and the chief $3,800.



Public Health Services 155



Bureau of Laboratories

THE work of the Bureau of Laboratories is carried on under the super-
vision of the Chief of the Bureau, known as the Director of Laboratories,
at present a part-time employe, also occupying the chair of bacteriology
and hygiene at Western Reserve University Medical School. Two laborator-
ies are maintained, one the bacteriological laboratory for the examination of
cultures, smears, blood specimens and pathological specimens for the diag-
nosis of disease, and the examination of water, milk and other substances for
their safety and purity as foods. The second laboratory is a chemical labora-
tory and is charged with the analysis of food and drugs, the sanitary super-
vision of stores, restaurants, bake shops and the like.

The ordinance authorizing the bureau provides that the function of the
laboratory shall be to assist in the diagnosis of communicable disease, to fix
the period of quarantine, to determine the quality of the milk, food and water
supply of Cleveland, and to perform such chemical and bacteriological
analyses as are related to public welfare.

The functions of the laboratories are similar to those of other municipal
health laboratories: i. e., diagnosis, analysis, production, research. The out-
fits supplied for diagnostic uses are assembled but not manufactured at the
laboratory and there are no biological products produced as a routine by the
city.

The Chief of the Bureau of Laboratories, under the direction of the Com-
missioner of Health, has charge of all employes of the bureau, assigns their
duties and enforces the laws relating to the functions of the bureau.

The bureau supplies outfits for the collection of material from suspected
cases of diphtheria, typhoid fever, tuberculosis, rabies, and such other com-
municable diseases as the Commissioner of Health and the Chief of the
Bureau of Communicable Diseases may decide.

No diagnostic services are provided for meningococcus or other organisms
causing meningitis or for pathological changes in the spinal fluid. No type
determinations are offered for pneumococcus or meningococcus. No tetanus
antitoxin, antipneumococcus vaccine or antimeningococcus serum are avail-
able through the laboratory or any bureau of the Division of Health. Viru-
lence tests for persistent diphtheria carrier organisms are rarely made (in per-
haps 10 to 12 cases a year) and then by the lethal test instead of by the more
economical and quite as reliable intradermal test in guinea pigs.

The bureau examines and reports on samples of milk and dairy products
submitted by the Bureau of Food and Dairy Inspection, and such samples
from other sources as may be approved by the Commissioner and the Chief of
the Bureau of Laboratories.

The laboratory's activities in milk examinations were as follows:

There were 12,245 milk samples examined; 10,016 shipper's samples and
2,229 dealer's samples. Four per cent of all were below the lactometer



156 Hospital and Health Survey

standard; 5.5 per cent below the fat standard; 27.5 per cent below the total
solid standard and 19.7 per cent below the standard of cleanliness by the sedi-
ment test.

When shipper's samples are found to fall below the legal standards,
written notices are sent to the producer calling his attention to these facts.
Later, averaging perhaps two months from the time the notice was first sent,
an effort is made to secure samples of milk from the same producer to see
whether or not the fault complained of has been corrected. This is poor
follow-up and leaves too much to chance and the good will of the shipper.

No bacterial counts were made of the shipper's samples of milk, but it is
stated that 50 per cent of the dealer's samples had more than 50,000 bac-
teria to the c. c. (It should be remembered that the milk ordinance speci-
fies 500,000 as the bacterial standard for milk which may be sold in the city
of Cleveland.)

The bureau makes chemical and bacteriological examinations of the
municipal water supply (including samples from springs in parks) at approved
intervals, as well as sanitary examinations of water used by citizens of Cleve-
land at their homes in the city or country. It also examines from time to
time such water as is offered for sale. The bureau makes such chemical,
bacteriological and pathological examinations of samples of foods submitted
by the Bureau of Food and Dairy Inspection as may be necessary. It makes
tests as to the bactericidal efficiency of disinfectants and germicides.

The work of the bacteriological laboratory is carried on by a staff con-
sisting of a director on part-time, and four other persons, two of whom are
listed as bacteriologists, one as a physician, the other as serologist. One of
the four named above has, under the director of the bureau, general super-
vision of the laboratory. There are four laboratory assistants, one who
cleans glassware, being classified as laborer, one messenger and two typists
as clerical assistants.

The following summary of the work of the bacteriological laboratory indi-
cates the types of examinations made and their number in 1919. 45,711
specimens were examined, an increase of more than 50 per cent over the num-
ber examined in the previous year. Specimens of sputum, blood for Widal
tests and the heads of animals for the diagnosis of rabies, showed a decrease
in number. The decided increase in total specimens was due to an 83 per
cent increase in throat cultures and the increase in the number of blood
specimens sent in for Wassermann tests and of smears for gonococcus. Diph-
theria having shown a low incidence in the three years previous to 1919,
became more prevalent during that year, and this increased prevalence
accounts largely for the increased number of cultures. It is not unlikely,
however, that more exposure cultures were taken than has been usual in the
past since this procedure was made very extensive whenever diphtheria oc-
curred in schools or institutions. The probable truth of this inference is
indicated by the fact that while diagnosis cultures increased 66 per cent,
exposure cultures more than doubled in number. There was a diminution
in sputum specimens from 3,216 in 1918 to 3,101 in 1919, and from 764 in
which the tubercle bacillus was found in 1918, to 630 in 1919.



Public Health Services 157

Increasing interest in venereal disease control may well explain the in-
creased number of examinations for their diagnosis. Wassermann speci-
mens presented for examination increased from 5,807 in 1918 to 8,070 in
1919 and the positive findings from 1,498 to 2,658.

An approximate estimate of the cost per specimen is 33 cents for all
diagnostic tests.

The chief criticisms of the laboratory which have been heard relate to the
dependability of its reports in laboratory diagnoses and upon the maintenance
at the distributing stations of a proper supply of outfits for the collection of
material for diagnosis, and of diphtheria antitoxin for use in immunization
and treatment of diphtheria patients and those exposed to diphtheria.

In general, according to the judgment of physicians having experience in
this matter, it appears that the Wassermann work of the city laboratory is
of high character. A similar statement would undoubtedly be made of the
morphological differentiation of the pseudo-forms from the true forms of the
diphtheria bacillus. In diphtheria particularly it is probably true that a



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