and definitely determine from what source the water received its infection.

The following tabulation presents certain details regarding the nine cases which occurred, the third having been unreported:

The diagram shows the location of cases.

Menands road is situated on a sharp slope, rising from Troy road toward and beyond the railroad. Other houses than those involved, several of which were located on the south side of the street, are not shown on the accompanying diagram. The hillside is made up largely of a loose shale rock, which comes to the surface at many points. Along the south side of the road is a sewer laid several years ago. On the grade, west of the railroad and north of Menands road is a cemetery to which a large number of bodies had been transferred during the spring. During the spring and up to within a week of onset of the later cases, the ground had been saturated with water, and it was said to have been necessary to pump out graves in the cemetery before transferring bodies to them. The toilet at the D. & H. R. R. station near Menands road is connected with the sewer shown in the diagram.

Most of the houses in this section receive water from the Watervliet public supply. Inasmuch as this supply was generally considered unsafe and unfit for use, most of the residents of Menands resorted to wells for their supply of drinking water.

The first case, E. L., onset April 1, apparently received his infection from an independent source. The second and third cases who were contact cases with E. L., M. K., L. H., C. A. and

H. H. with onsets June 4, 12, 10, 14, respectively lived in the row of houses from 25 to 33 Menands road, and obtained their drinking water from a well at No. 29. The members of the household at No. 29 where there were no cases were elderly adults.

The well at No. 29 was a driven well about 50 feet deep. About June 20 it became impossible to pump water and investigation revealed the fact that the casing was broken. After that time, knowing that the well water was regarded with suspicion, the owner had disconnected the handle, so that the neighbors could not use the water. For some time prior to that time, persons using the water had apparently been boiling it.

D. C., onset June 17, was a school boy living at a considerable distance from the cases referred to above. About two weeks before onset he had been working in a school garden and had several times drunk freely of the water from the well at No. 29.

A. C., Clifford Ave., onset June 12, was a salesman whose travels took him regularly to Watervliet and Troy. In Watervliet typhoid was usually prevailing to some extent. His water supply when at home came from a dug well indicated on the diagram. This well was located at the foot of a steep grade, a short distance below the well at No. 29.

About two weeks before his onset, water had been standing in an excavation near his home. The water in the well usually became turbid after every heavy rain. It was stated that a sample had been examined at a private laboratory; his only information was that it was of a poor sanitary quality. It is not unreasonable to assume that this well may have been subject to pollution at the same time as the well at 29 Menands road and from the same source.

In addition to the cases described there were three cases in the houses indicated on Menands road, which were suspicious but in which the attending physician had made other diagnoses than typhoid. All had used well water from No. 29 regularly.

INSTITUTIONAL OUTBREAKS

Typhoid cases have occurred from time to time in a number of the state hospitals for the insane. Early in the year the matter was taken up with the State Hospital Commission from which

directions went to hospital superintendents that all future admissions be vaccinated against typhoid. Since that time vaccine has been furnished to the hospitals by the laboratory of this department.

During August, 16 cases of typhoid occurred at Trudeau Sanatorium, Saranac Lake, the onsets of 15 occuring between August 15 and 31. A state epidemiologist and Dr. William L. Munson, sanitary supervisor of the district in which the institution is located, were assigned to investigate and assist in control of the outbreak. After a detailed investigation it was determined that infection had probably occurred through handling of food supplied to one dining room. Samples of excreta from 79 persons regarded as possible carriers were examined with negative results. One of these persons, employed as a waitress, and having general charge of the placing of glasses, silverware and linen, gave a partial Widal reaction. A single fecal sample showed no typhoid bacilli. Unfortunately, this young woman and one or two other employes left the institution at about this time and were lost sight of. There were, however, no subsequent cases.

A few particularly interesting paragraphs extracted from the reports filed by the investigators follow:

"Because of the difficulty in differentiating typhoid from an exacerbation of tuberculosis in patients with pulmonary tuberculosis, blood cultures were made from the first few persons taken ill. The culture showed very actively motile Gram negative bacilli, which clumped upon the addition of immune typhoid serum. After the definite character of the infection was known, Widals were used for diagnosis.

"The routine work of the institution, so far as possible, was dropped and the entire attention of the staff was focused on getting the patients with typhoid isolated. The infirmary was converted into a typhoid hospital and here all the patients who ran an unusual or unexplainable temperature were taken as suspicious cases of typhoid. These suspicious cases were isolated from the rest of the known cases of typhoid. The usual methods of precaution, disinfection of the stools and urine, washing of attendants' hands, sterilization of bed linen, dishes, etc., and the rigid exclusion of flies were carried out with the suspicious cases

as well as with the known cases. It is noteworthy here to state that but two patients were isolated who did not develop frank typhoid fever. As all patients running a temperature not definitely known to be from tuberculosis were put upon precautions and watched, it is probable that no cases of typhoid were missed.

"The question as to whether or not patients with active tuberculosis should be injected with typhoid vaccine was not known and so far as we were able to ascertain had never been done in any institution for the care of tuberculosis. Due to the uncertainty of the source of the infection. Dr. Lawrason Brown advised that all patients be vaccinated. Form August 28 to 31, 172 of the employes and patients were vaccinated. All patients were immunized save those who were very ill with tuberculosis. A very careful record was kept of the results of the vaccination in all the patients as regards reaction, effect on existing tuberculosis, temperature, etc., and will be the subject of a report by Dr. Fred H. Heise, resident physician of the Trudeau Sanatorium. The reactions were about the same as seen following the vaccination of the nontuberculous. There were noted no unfavorable immediate results.

Except in

"The character of the infection was selective. two instances the persons attacked were patients with tuberculosis who were up and about and eating their meals in the main dining room. Patients who were confined to the bed and were being served exclusively by trays, with one possible exception, were entirely untouched by the infection. Patients at the infirmary, served with food prepared in the infirmary, were also free from typhoid."

Early in September Dr. C. R. Hervey, sanitary supervisor, investigated a series of eleven cases which were reported during the latter part of August from the Wayne county home.

It was found that the first case had been ill upon admission to the home in July. During his illness and until he was removed to a Rochester hospital, his discharges were thrown untreated into a flush closet, the sewers connected with which discharged into a canal situated some fifty yards from the main building.

A sluggish current in the canal tends toward the east. About 35 feet east of the sewer outlet was an intake through which water to be used for laundry purposes, flushing closets, washing dishes, faces, hands, etc., was pumped to the institution. The supply of drinking water came from a spring, and was pumped by the same pump into separate pipes. For about three feet on the intake side of the pump a common pipe was used for both supplies. It was customary before pumping spring water to the reservoir used for that purpose to flush the intake pipe with spring water. While pumping spring water, the canal intake was closed by a valve located approximately three feet from the junction of the spring and canal intakes. This left a dead end in the canal intake capable of holding a small quantity of the polluted water. Pollution occurring in this way, at a time when the sewer was discharging infective material from the first case, was apparently responsible for the, subsequent cases.

For its possible interest in connection with our efforts to encourage more systematic and effective investigation of typhoid cases and outbreaks by local health officers, there is appended an article prepared by the writer for publication in HEALTH NEWS.

THE CONTROL OF TYPHOID FEVER

The investigation of a recent typhoid fever outbreak has brought to light conditions which, while not new, are worthy of serious consideration. It was found that there were numerous cases which had never been reported; others in which reports had been delayed beyond all reason, assuming average diagnostic ability on the part of attending physicians; still others in which snap-shot" diagnoses had been made without resort to laboratory aids which were easily available. Notwithstanding the fact that it is now a matter of common knowledge that typhoid fever has been practically eliminated from the armies of the world by antityphoid vaccination, a safe and simple procedure, only in rare instances had the members of families in which there were typhoid cases been immunized, and some families had never even heard of it.

No communicable disease can be controlled unless we can know where the cases are and how they received their infection. Practising physicians are the scouts upon whom we must depend to keep us informed as to the location of the enemy. The laws requiring immediate reporting of cases are both reasonable and specific. With due allowance for the necessary margin of delay on account of the difficulty of diagnosis in some cases, the interval between onset and report should rarely exceed ten days in the hands of physicians of average diagnostic skill. if they are willing to use and able to interpret the results of laboratory procedures, and, desire to live up to the