diarrhea, but no typhoid. This diarrhea is mostly confined to tourists. Residents do not suffer from it. At St. Petersburg there was much diarrhea this year. The water may have slight laxative action. There was no diarrhea in the village of Belleair (residents and users of lake water supply). The occurrence of diarrhea is apparently independent of the typhoid fever. Recommendations In order to avoid a possible repetition of this year's experience, we recommend the following: I. That the milk and cream supply be obtained from a source the sanitary conditions of which are known to be safe. This may be accomplished through the agency of the distributing company, but the satisfactory condition of the producing dairy or dairies should be confirmed at frequent intervals during the hotel season by personal visits of an accredited representative of the hotel management. 2. That a similar censorship be maintained as far as possible over other food supplies of the hotel. 3. That certain projected changes looking toward the removal of stables, etc., to a more remote portion of the hotel grounds, be carried That the dining room and kitchen be adequately screened against 5. That the water faucet at the 5th tee be arranged so that the golfers cannot drink the lake water, and that the water supply at the kitchen sinks be so arranged that the lake water cannot in any way come in contact with vegetables or other food. Also, that adequate spring water be supplied in the quarters of the help. These recommendations as to the lake water are made as a safeguard against future trouble, and not because we believe that the lake water had anything to do with the typhoid outbreak of this year. As matters stand at present, the lake water is a menace only in that it is possible that at any time typhoid bacilli might be introduced into the lake, and an epidemic develop before infection was suspected. A more extended use of spring water is desirable. So far as the available supply is concerned, this is feasible, since at present only a little over 2 per cent. of the flow of the spring is being used. (Enclosure with above report:) Drs. Irons and Wilcox, Clearwater, Fla. (Signed) EDWIN O. JORDAN, ERNEST E. IRONS TAMPA, FLORIDA, May 6th, 1911. GENTLEMEN: Complying with your request, we attach herewith in duplicate statements from our records showing entire purchases of milk and cream covering the dates fully that you requested. In addition to this, the writer will take pleasure in personally showing you all of these dairies and furnishing you any other information that you desire in this connection. As a matter of information, we would like to call your attention to the following facts: Ist. That during the period covering this report we received 300 gallons of milk and, at times, 30 gallons of cream. 2nd. That the Belleview purchased not to exceed at any time during this period 25 gallons of milk and 20 gallons of cream, and this amount was during the months of February and March, the amounts in January and the last few days in March being nearly half this amount approximately. 3rd. That in addition to the cream purchased above, we separated from the milk purchased from 25 to 30 gallons daily at our plant. 4th. That we furnished practically every restaurant in Tampa, and 75 per cent of the drug stores and cool drink establishments, and we conduct a retail store that dispenses 25 gallons of milk and 10 gallons of buttermilk daily. 5th. That we furnished during the same period the Tampa Bay Hotel about half the amount furnished the Belleview, and that we supplied them exclusively, no other milk having been purchased by them from any other source. Also, we furnished the DeSoto about the same amount of milk as the Tampa Bay, and supplied all the ice cream used by them for the entire season. That the combined guests of these two hotels alone would, we believe, exceed the number at the Belleview, not taking into consideration the patrons of the restaurants and cool drink establishments. 6th. That we made in January 700 gallons, February 850 gallons, March 1100 gallons of ice cream from the above products, and sold the same locally, and to several adjacent towns. 7th. That we have heard of no cases of typhoid fever or any contagious disease in any of the above establishments. All of which we respectfully submit for your consideration. By..... PREVALENCE OF TYPHOID FEVER IN TAMPA The first feature of their report to which attention is invited is the statement that "A conservative estimate of the cases of typhoid fever in Tampa during March and April would be from 100 to 200 cases." I have been unable to get a record of anything like this number. The records I have been able to obtain show 7 cases for February, 9 for March and 12 for April. Assuming that the February cases were all carried forward into April, we have only 28 accounted for. The deaths for March were 2, April 3 and May 2. Taking the deaths as a basis, it will be seen that the deaths for March and April, or for April and May, were only 5. Assuming that the mortality is about 12 per cent., this would give us some forty cases for the two months. So taking all the obtainable facts. and putting them together, I fail to find any evidence that the disease was so widespread as alleged. It would seem to me that 25 to-at most-50 cases for the months of March and April would have been a very liberal estimate. P. H.-21 With this exaggerated estimate of the number of cases staring me in the face, I can 'proceed to the other features of the report with less trepidation. CREAM The next feature to be considered is found in Part VI, under the caption Cream. The statement is made that "The daily consignment during the two latter periods were larger and though on some days they may have been sent to the local dealers in original packages, on other days they were mixed with the general supply of the Tampa Dairy Company, two-fifths of which went to the Belleview." It is the above statement that I want to speak of, because it is this that enables the cream from this particular dairy in Tampa to get to the Belleview. And that statement is at variance with the information furnished me by Mr. Barritt and borne out by the office employees of the Tampa Dairy Co. It was the same Mr. Barritt who gave Dr. Irons his information. Mr. Barritt tells me that it was not their custom to mix the cream from Fisher's dairy with the regular supply, but on the contrary, it was their custom not to do it; and that if it ever was done he is unaware of it. While he cannot say positively that it never occurred, he confidently believes that such is the case. There are a number of circumstances that would bear this out. For example, The Belleview was that time one of the largest patrons of the Tampa Dairy Co., and it was the custom of the dairy to provide for their largest and best customers first, and from the regular supply that could be depended upon. Furthermore, they usually made up the shipment to Belleair in time to catch the early boat, which they could not have done had they not got the cream off before Mr. Fisher's delivery, which was usually late. Again, the maximum amount of cream received from Mr. Fisher on any one day was four gallons. At that time, Mr. Barritt informs me, he had in the vicinity of a dozen local patrons that took two to four gallons a day, and that it was his custom to supply the local customers with the cream that came in irregular quantities and at irregular intervals. Upon the whole, Mr. Barritt believes that he would be thoroughly within the bounds of truth if he were to say that none of the cream from Fisher's dairy ever went to The Belleview. He recognizes that there is the barest possibility that it might have occurred, but confidently believes that it never did. Now, since it was necessary for this cream to get over to The Belleview in order to connect the infection with Tampa at all, it will be seen what a slender thread of evidence the whole case against the Tampa Dairy Co. hangs upon. Nor does it stop there. If this obstacle were safely past and it were shown that the cream from the dairy in question did actually go to The Belleview, they would yet have to pass another that is still more stubborn. For it has not been shown that the consumption of milk and cream from Fisher's Dairy has produced a single case of typhoid fever. As we have seen in this report, there is not a particle of epidemiological evidence that milk has played any appreciable part in the typhoid prevalence in Tampa, and this in spite of the fact that Mr. Fisher's entire output, from a herd of sixty-eight, has been distributed there. Furthermore, at the time the Tampa Dairy Company was supplying The Belleview, it was also supplying the Tampa Bay Hotel and the DeSoto. And it did supply cream from Fisher's dairy to both these places. No case of typhoid fever is known, or suspected, to have been contracted at either hotel. The evidence in support of the position taken by Drs. Jordan and Irons may be summarized as follows: ver. I. That certain guests of The Belleview developed typhoid fe 2. That The Belleview got a portion of its cream from the Tampa Dairy Company. 3. That the Tampa Dairy Company got a very insignificant portion of its cream from W. A. Fisher. 4. That Fisher's dairy was in an unsanitary condition, and 5. That (possibly) some of Fisher's cream reached The Belleview Hotel. The evidence against that being the source of the infection at The Belleview may be summarized as follows: I. That (probably) none of Fisher's cream reached The Belleview. 2. That the Tampa Dairy is known to have supplied Fisher's cream to both the Tampa Bay Hotel and the DeSoto Hotel, and no case of typhoid is known or suspected to have originated in either. 3. The rest of Fisher's entire output from a herd of 68 was distributed in Tampa and consumed by the Tampa people, and yet there is not a particle of evidence that milk has played any appreciable part in the typhoid situation in Tampa. From all of which it would seem that the evidence to convict the Tampa Dairy is totally inadequate, and the fact of guilt highly improbable. FLY INFECTION Typhoid outbreaks have characteristics according to the source of the infection. A water infection is characterized by being explosive in character, covering the territory supplied with the infected water, and limited largely to that, and yielding suddenly to remedial measures directed thither. A milk infection is due to a typhoid carrier handling the milk, and the disease will follow the route of the dairy so infected. While a fly outbreak is more or less gradual in its onset, reaching its low mark during the months when flies are fewest, and its corresponding high mark when flies are most abundant. There is no evidence that the water in Tampa has had any connection with the typhoid prevalence, nor is there any evidence that milk has played any appreciable part. But there is strong epidemiological evidence that the disease has been chiefly fly-borne. There are several things that bear this out. There are approximately fifty-four thousand people in Tampa. The central portion of this aggregate of human habitations is sewered. In the sewered portion about twenty-five thousand people live, while the remaining twenty-nine thousand live in the surrounding unsewered territory. In other words, there is a sewered city of twenty-five thousand people, surrounded by an unsewered city of twenty-nine thousand. In the unsewered portion open closets are the rule. No attempt is made to make them fly-proof. Flies have easy access both to the privies and the homes-kitchens, dining rooms, bed rooms. Where these conditions prevail, they visit the privies and the homes alternately. They carry on their feet excreta from the privies to the pantries, tables and wherever they can find food spread or some one to worry with their attentions. Wherever there is an open closet in the community there is danger, for sooner or later some one that has recently had typhoid fever and is still excreting typhoid bacilli will use that closet. And |