Though practically all large and explosive epidemics are due to contaminated water and milk supply, a goodly number of severe epidemics have been traced to an infected food supply. Thus in a recent issue of the Journal of the American Medical Association (Oct. 31, 1914), Dr. Wilbur A. Sawyer gives an account of an epidemic in which ninety-three cases developed from the eating of Spanish spaghetti which had become infected by an unsuspected chronic typhoid-carrier who prepared this article of food. The typhoid bacillus was isolated from the feces of this woman, and the food probably had been contaminated by the means of unclean hands. Of unusual interest is the fact that this woman never had typhoid fever, though thirty-five years previously she had nursed a daughter through a severe attack of it.

Now as to the second measure of prophylaxis. It is here that the private practitioner is directly interested. The handling of sporadic cases is under the supervision of the attending physician, and it is to him particularly that we look for such regulation as will prevent the development of endemic cases. The continuance of any epidemic after the original source of infection is under control can be prevented only by the most thorough watchfulness on the part of those in charge of the individual cases. Sporadic and endemic cases arise by direct or contact infection, and many epidemics also result in this manner. As was pointed out in my paper heretofore quoted all such cases arise through the infected excretions of the patient. In some instances the germs from the excretions are carried into the water or milk supply, and a widespread epidemic is thus established. The danger of infected feces, urine or sputum contaminating the patient's bedding, eating utensils and all other articles used in the sick room is an imminent one. The physician, nurse or others caring for the patient, and bedside visitors, may thus easily become contaminated and contract the disease or carry it to near or distant parts. The possibility of flies and other insects, rodents, household pets, etc., carrying the disease must not be too lightly reckoned with.

It is the duty of the attending physician to enforce as nearly as possible all rules necessary to prevent contact infection by setting an example in the scrupulous care of his person, that it does not become contaminated, and by insisting that the nurse or others in attendance carry out, to the minutest detail, all recognized preventive measures, such as the thorough disinfection of the feces, urine, sputum, bath water, bed clothing, eating utensils, etc., care of their own hands and persons, and the establishment of means whereby the danger of fly and similar infection may be reduced to a minimum. The access of visitors to the sick room should be curtailed as much as possible. To prevent the entrance of flies into the sick room seems a Herculean task, but much can be done by proper screening and the placing of fly traps of various kinds in proper places. A vigorous campaign against the propagation of these pests should at once be inaugurated. Thus proper disposal of all slops, manure and other filth on or about the place should be made. All manure piles should receive plentiful and repeated treatment with chloride of lime, or, better still, the manure should be dumped into closed

bins, into which no flies can enter, and each new supply of manure should be treated with chloride of lime. The manure in this bin should be carried away from the premises at least once a week. The slops should be buried deeply in the ground or received in receptacles which allow of tight closing. As an illustration of the danger from contact infection I wish to cite some -forceful examples. About seven years ago there was a mild outbreak of typhoid fever on the male wards of the Independence State Hospital. As Dr. Donohoe was away at the time the care of the typhoid cases was allotted to me, and I was asked by the superintendent, Dr. Crumbacker, to instruct the nurses in the proper handling of such cases. Practically the same rules as were recently adopted at the Clarinda State Hospital were put into effect. Upon my first trip to the ward where the two initial typhoid cases were confined I learned that a number of the inmates who were willing helpers had been allowed to carry the patients' soiled bedding from the room to the dirty clothes receptacle. Of course this practice was at once discouraged, and the nurses were given a talk relative to the grave danger arising from the careless handling of such contaminated articles. Five patients had been thus employed. First one would do the work, then another and so on. Of these five men three soon contracted typhoid fever. When we consider that but eight cases developed at this time this feature assumes grave significance. One of the nurses in charge of the typhoid patients failed to carry out instructions relative to the care of her hands after waiting on them in that she frequently handled her keys while her hands were contaminated. She had the dirty habit of putting the keys in her mouth. These things she confessed to me after she was taken sick. In every other detail she had been most careful. I am convinced that she contracted the infection by carrying contaminated matter from her hands to the keys and thence to her mouth.

One of the greatest problems met in an endeavor to prevent typhoid epidemics is the great difficulty of early diagnosis in mild or irregular cases. All doubtful fever cases, of from three to four days' standing, should be considered typhoid fever and handled as such until clinical and laboratory findings establish their true nature. Blood cultures should be made very early or the blood should be tested for the Widal reaction. These tests should be frequently repeated as long as any doubt remains as to the nature of a given prolonged case of fever. Blood cultures, as I pointed out in my paper heretofore referred to, are of most value and frequently establish a diagnosis many days before the Widal reaction is in evidence. The difficulty of early application of these laboratory tests is greatly enhanced in rural districts far removed from a clinical laboratory. Numerous such laboratories should be established throughout the state and placed in charge of competent men, to facilitate the matter of early diagnosis and for the purpose of assisting local health officers in carrying out such investigations as are deemed advisable in efforts to discover the source of typhoid infection and also to aid in devising means for its prevention and control.

There is one factor which I believe should stand preeminent in our consideration when adopting measures towards the prevention and final

ease.

elimination of typhoid. I refer to the so-called chronic typhoid carrier. Any one who has passed through a siege of typhoid fever may become a chronic carrier, and many who come in contact with the infection have been shown to harbor the bacillus without ever developing symptoms of the disChronic carriers become such, particularly through the colonization and multiplication of the typhoid bacillus in the gall bladder, from whence the germ is discharged, in greater or less numbers, into the intestine during the normal functioning of this organ. That a person so infected is capable of disseminating the contagium to others, and is frequently responsible for precipitating large and devastating epidemics, is definitely proved by incontrovertible evidence in a large number of classical instances.

The problem which confronts us in the discovery and control of such cases is indeed weighty and is fraught with difficulty, but I wish to state most emphatically that it is far from being uncontrollable. The near future, fostered by clearer understanding of this menace and encouraged. by better technical measures directed to the discovery of carriers, is bright with favorable possibilities. As the matter stands to-day, however, but little systematic effort is made in this direction except in our better general hospitals and in a few of the more enlightened states. Thus we see state and township health officers making little or no effort that proper examination be made in an endeavor to discover and control these cases. They have little or no support in legislative enactment. Right here I wish to emphasize that every township health physician, in whatever community he may be situated, can, with the cooperation of the other township officers and the other physicians of the community, do much towards bettering conditions through systematic and untiring efforts. Of course this assumption presupposes the possession of an intelligent grasp of the subject and a progressive spirit on the part of the health physicians.

The first essential is the schooling of the public in all matters pertaining to this as it is now being educated in matters relative to some other infectious diseases, so that its hearty and enthusiastic cooperation may be enlisted. All should be taught how to live that their own and their community's health is the better safe-guarded. Public lectures on all the phases of typhoid fever and other infectious diseases should be given by the various enlightened physicians of the community, and these talks should be printed in pamphlet form and distributed to every family in the district. So far as the consideration of typhoid fever is concerned, special attention should be directed towards its many modes of dissemination. The subjects of contamination of the water, milk and food supplies, the danger from the typhoid carrier, etc., should be fully and forcefully presented, and the various means of prevention and control discussed, due emphasis being given to the advisability of more or less complete isolation of typhoid cases and the potency and harmlessness of antityphoid vaccination. I repeat, such efforts should be everywhere inaugurated, at least until an enlightened legislature will empower the various health bodies to enforce such procedures.

I will now enter upon the discussion of the third method of typhoid prevention, that of artificial immunization.

The basis upon which rests the rationale of prophylactic treatment of typhoid with vaccines is the well known fact that an attack of typhoid confers on the individual a more or less lasting immunity from the disease and the harmlessness of the procedure. As early as 1896 two Germans, Pfeiffer and Kolle, and Wright, of England, began the practical application of vaccines as a prophylactic measure in typhoid. Their methods have been modified as to minor details by Wright and his coworkers, though the principles have remained the same. However, the early failures to establish immunity in the British Indian and South African army prevented any serious consideration of its further use until it was shown by Leishman that much of the vaccine was overheated and, in consequence, its antibody stimulating effect greatly diminished.

In 1909 Col. Leishman published his results in certain selected Indian regiments, and these results were so striking as to encourage its use by our army officers. Thus in our army antityphoid vaccination was begun voluntarily in 1909 and was made compulsory in 1911. In 1911 orders were suddenly issued for mobilization of troops in Texas and California, along the Mexican border. About 25,000 troops were thus quickly assembled in places entirely unprepared so far as modern sanitary measures are concerned, under identical conditions of active field service. All these soldiers not already vaccinated against small-pox and typhoid at once had to submit to the treatment. Despite the fact that for a week or more after mobilization had taken place sanitary measures were far from complete, and also in spite of the fact that the soldiers were allowed to mingle among the civilian population, drinking the water and eating the food of these people, among whom were several hundred cases of typhoid fever, only two cases of typhoid developed among them. One of these was very doubtful, not giving the special reactions, and running a very mild course.

Contrast these results with those at the mobilization camp at Jacksonville, Florida, during the Spanish-American war. Here were situated only 10,759 troops, among whom developed 1,729 cases of certain typhoid and 2,693 cases of certain and probable typhoid, with 248 deaths from the disease. Of course we must not overlook the fact that sanitary conditions in this camp were not as they should be. This applied particularly to the disposal of refuse and human excreta, and the poor handling of the fly situation. Here no systematic attempt was made to control the fly situation while along the Mexican border this evil was reduced to a minimum. It was definitely proved that the epidemic at Jacksonville was fly borne. Their water supply was of the best being secured from artesian wells; much superior, in fact, to that obtained along the Mexican border. Also when we remember that along the Mexican border the soldiers were allowed to mingle, and in many instances live, among the civil population of San Diego, San Antonio and Galveston, among whom were numerous cases of typhoid fever, eating the same food and drinking the same water, we can

not attribute the nonprevalence of typhoid to improved sanitary conditions alone. In further proof of this contention, that prophylactic vaccination and not improved sanitation is chiefly responsible for these excellent and pleasing results, it might be well to mention that in 1911 a cavalry regiment of seven hundred men engaged in a twenty-one days' forced march through Tennessee, where typhoid fever is always more or less prevalent. During this march of six hundred miles there was no attempt to boil or sterilize the milk or water obtained along the way. No cases of typhoid developed because the soldiers had been previously immunized against the disease by proper vaccination. These, and many other proofs, which have accumulated recently, of the efficacy of typhoid vaccination over modern sanitation alone, should for once and all time put a stop to the pessimistic pratings of all, especially such of our own profession whose words, among a number of their medical brethren and lay following, are accepted as authoritative.

The success attendant upon efforts of vaccine prophylaxis of typhoid in the army has stimulated energetic and successful measures everywhere to the same end. Thus most general hospitals, many manufacturing corporations, large lumber camps, etc., have adopted it, and we now find nurses, physicians, employes and many about to embark upon a long journey submitting to voluntary or enforced vaccination. And yet, despite incontrovertible proof of the efficacy of this measure and the absolute harmlessness of the procedure, we still find open antagonism, pessimism and, worst of all, indifference on the part of many whose chief function should be the safeguarding of the public against this as against other diseases and this most valuable measure ignored or actually condemned as of little value or worthless. How many physicians, think you, when called to attend a private typhoid patient, employ or attempt to employ the most modern sanitary precautions, including particularly vaccination, among the members of the household or among those of the community exposed to the disease? Very few indeed.

Immunity from typhoid, following vaccination, averages about two years. Sensitized vaccine, recently tried, is said to be most potent.

Before entering upon a brief discussion of the typhoid epidemic which we, at the Clarinda State Hospital, were so unfortunate as to have, I wish to call attention to what several states, notably Washington, Minnesota and Maryland, are doing towards the control of infectious diseases, particularly typhoid fever. Thus laboratories under the direct charge of competent men are scattered throughout these states at convenient points. A commissioner of health is appointed. He must be a physician with a record of at least five years' successful practice and versed in sanitation and laboratory methods. His duty is to cooperate with the board of health to the extent of enforcing all the rules promulgated by the board towards the prevention and control of infectious diseases, etc., to visit and cooperate with the local health officers in the handling of epidemics, and to supervise the work of the various laboratories under the board. In these states typhoid fever cases are isolated and the houses properly placarded, and members of the family are not allowed to attend public meetings or to mingle pro