hoa nnt the num-
Unfortunately our army as now constituted =- ----. .-~
ber of medical men it should have, and one of our dutres as men
interested in our country's welfare is to urge provision for the full
number of properly trained army surgeons.
The prompt and proper care of the wounded is one of the great-
est problems of modern warfare, and the greatest opportunity
is afforded for medical workers to prevent unnecessary suffering
and death. Tales are reaching us of the number left wounded
and dying for days on the battlefields of Europe. This we know
is one of the horrors of war, but to minimize these condrtrons as
much as possible is one of the privileges of the army surgeon.
                     T. W. GRAYSON.

THE DISEASE CARRIER ON TRAIN AND S'I'EAMBOA+.i
By Wr~sva A. SAWYBB, M.D., Director of the Hygienic taboratory of the California

The traveler runs a greater risk of contracting disease than does
the man who stays at home.   .J
             He enters a large number of com-

State Board of Health. Berkeley.

munities with varied climates, and is apt to come into'contact
with acute cases of contagious disease, with chronic disease-
carriers, and with disease-bearing insects. In this way he `is
likely to be exposed to diseases against which he has acquired no
specific immunity, as he has had no experience with them:?`:.at
home:

Infections taking place on trains and steamboats,. while'sec-
ondary in number to infections in the communities ;oisftedj' are
nevertheless deserving of special consideration. A part of-these
infections are traceable to disease-carriers-persons who j are
healthy but nevertheless harbor and discharge germs'~capable
of producing disease. ' * " ' :                            .-  . . . .
' In certain respects the disease-carriers `on raih-oadc and steam;
boats are more dangerous than if they were not traveling, `&ho
this increase in danger is to a degree offset. by sanitary sup&
vision usually exceeding that exercised by health officers. at' the
carriers' homes. The carriers, when traveling,' come' into eon-
tact, often under conditions of crowding, .with p&ple going to
many IocaIities. The persons infected by such carriers introduce
the disease into their widely separated communities. * Moreover
the carrier who is traveling is less likely to be discovered and
controlled than the one who stays at home, because his victims
are widely scattered and have little notion as to the source of
their infection. Attention is not called to him by recurring
cases of the disease in his neighborhood.
The diphtheria carrier is our best known representativ of those
carriers who distribute infectious germs in the secretions of their
noses and mods.  On both trains and ships the limited space
increases contact between passengers.  Necessarily, the passen-
gers, one after another, in rapid succession, handle fixtures, such

' Read at the 40th Annual Meeting of the American Academy of Medicine. San Fran-
dsco. June 28, 1915


I32

as doorknobs and hand-rails, and thus make opportunity for the
transfer of infection from hand to hand and then to mouth.
They often cough and sneeze in close proximity to each other.
Before the common cup was abolisht on interstate carriers, it
furnisht an almost direct method for the transfer of diphtheria,
common colds, and the like.

Instances are not infrequent in which people have developt
diphtheria at the close of a railway journey in which they did not
knowingly come into contact with a sick person.  Some of these

persons were undoubtedly infected by carriers among their
fellow passengers.

That dangerous carriers travel in considerable numbers cannot
be doubted. A proved instance of a carrier of virulent diphtheria
bacilli traveling by train and boat occurred recently in Cali-
fornia. A school-girl who had past thru an attack of diphtheria
was releast from quarantine after a single negativ culture, instead
of the two required by the State Board of Health, and was
allowed immediately to travel by railroad and boat to her home
at the lighthouse on the I?arallone Islands, which are situated
in the Pacific Ocean about thirty miles west from San E'rancisco.
Within a week her brother contracted a fatal attack of diphtheria
and soon afterward examinations showed that two of the thirteen
persons on the island had become carriers, and that the girl who
brought the disease to this isolated community still had diphtheria
bacilli in her throat. If any persons were infected by her during
her trip to her home, it is not likely that they would have any
idea as to the source of their infection.  Had it not been for the
fatal case at the end of her journey her carrier state would have
gone unrecognized.
Diphtheria carriers played an important part in an epidemic
of diphtheria on the United States Steamship Buffalo in 1903.'
The conditions were favorable for an outbreak because the ship
was crowded, and there was, therefore, unusual opportunity for
contact infection. The epidemic originated from an unknown
source, probably from a carrier among men recently taken ou
  1 Harmon, G. E. H.: Report of an Epidemic of Diphtheria on Board of the U. S. S. S.
ButIalo. report of the Surgeon-General. U. S. Navy, 1903, pp. 217-222.

                   133
board for training,  Among 750 men there were `1.37 cases, 18

                                                    , -
per cent. During the epidemic it was found that ;i per cent.
of the well persons, were carriers. The outbreak was per-
manently ended by leaving on shore all persons who persistently
gave positiv cultures.                                 
In epidemic cerebrospinal `meningitis we have a disease which
is spread largely by healthy carriers who harbor the germs in
their noses and mouths. Such conditions as would favor: the
spread of diphtheria would also increase the opportunity for out-
breaks of cerebrospinal meningitis.  We have an example of, an
epidemic of meningitis on shipboard in the experience of the
United States Steamship Minneapolis.' In 1903 the disease
was in all probability introduced into the ship either by a man
in the incubation period or by a chronic carrier. `The ship was
unusually crowded. There were 1450 men, on board while .the,
normal complement was 500 men. Under these .conciitionsan
outbreak of 23 cases occurred,                           ". L. '
In cholera, in dysentery (bacillary and' amebic) and in typhoid
fever we have three diseases which may be spread by carriers.`~
In all three the infectious agent is usually given off in the feces
and infects other persons thru the pollution of food or water..
According to PannenborgZ contact is a common method of
infection with dysentery on shipboard. He cites four instances
in which outbreaks of dysentery on German war-vessels could be
explained only on the supposition that they originated from
carriers. In tropical harbors, flies may perform an important
part in conveying infectious material to food.  If carriers have
access to the water supply there is danger that it will become
polluted and will cause an'outbreak of dysentery.
The danger from cholera in the United States at the present
. time depends entirely on the carriers who cross the ocean in
ships and infect persons en route and after landing.  Fortunately
we are being successfully protected against this menace by an
ef6cient system whereby immigrants are kept under observation
  `Stokes, C. P.: Report on Epidemic of Cerebraspinal Meningitis,
Minneapolis, report of the Surgeon-General, U. S. Navy. 1903. pp. 229-234.  u. s. s. s.
  * Panoenborg. A. E.: Die Gefshr der BazillentrHger und Dauerausscheider an Bard.
A?cbiv. fGr SchiBs-und Tropen-Hygiene, 1915. Vol. 19, Nos. I and 2. PP. 7-26 and 33-66.


Within the United States typhoid carriers are common; .and
some of them are very dangerous.  The number of these carriers
is being kept up by constant accessions from those communities
which fail to apply the well-known principles in the prevention
of this disease. Every city which permits conditions to continue
which produce a high typhoid rate is responsible for an annual
output of typhoid carriers, some of whom. will travel to `more
meritorious communities and help keep up the residual typhoid
fever there. As passengers or employees on railroads and shipa
these carriers will also be sources of danger.
The number of typhoid carriers produced is a fairly definit
proportion of the total number of cases. and therefore ..every,
precaution to reduce the typhoid rate will at the same time cause.
a diminution in the number of carriers. According: topriggesi ,'
five per cent. of cases of typhoid fever remain carriers, and there
are three carriers who have not past' thru a recognized attack
of typhoid `fever for. every seven who have; On this basis we'
reach `the conclusion that approximately. seven carriers are.~pr&!
duced for every one hundred cases which are allowed ,to occur.
Fortunately some of the carriers clear up and. many* do not infect
other persons.

The typhoid carrier, as a passenger'on `a train; is not specially
dangerous, but a carrier among the waiters or cooks on a dining
car might infect the food of many people.  Here are found *the
same conditions for easy transfer of disease which exist in a
public restaurant.
by carriers is   The danger of the infection of drinking water
    being greatly diminisht since the handling of ice

and the. cleaning of water containers, and the separation of the
ice from the drinking water have received so much attention in
the regulations of the United States Treasury Department and
the rules of the railroads.

On ships the typhoid carrier is more dangerous.  The passen-
gers live together, for a mare or less extended time, under condi-
tions of close contact similar to those in a crowded house.  Car-
riers among cooks and waiters would have their opportunities for
* Prigges, quoted by MBller. P. T.: Vorlesuogen Uber Allgemeine Epidemiologic.
1914. p. 9.

134

before they leave cholera-infected ports, and their feces are
examined bacteriologically before they are allowed to land in
the United States. In June, 191 I, prior to the order of the
Treasury Department requiring these bacteriologic examinations,
a few carriers gained entrance to the United States, but luckily
started no epidemics. The danger from cholera carriers on ship-
board was shown by the experience of ships arriving at the port
of New York between June 13 and August 18, 1911.' Sixteen
cases of cholera had developt on these ships while they were at
sea, fifteen more occurred during detention in quarantin, and
three after release. Most of these cases were due to carriers
among passengers and crew. The order requiring bacteriologic
examination of the feces of immigrants from cholera-infected
ports resulted in the discovery of thirty-one carriers on ships
arriving in New York from July to November, 191 I.  Only four
gave histories of cholera-like ailments. Two were from ships
on which there had been no recognized cases of cholera during
the voyage, and at least one of these men must have been a
carrier before embarking.

The danger from cholera-carriers is greatly reduced by the
short duration of the carrier state-seldom more than two
months. The stools of cholera cases are usually free from the
spirilla in twelve to fourteen days, and carriers who have not had
the disease are in most cases soon rid of their infection.
All the historic epidemics of cholera have spread along the
lines of travel, along the caravan routes across the desert, along
the trading highways of the ocean, along the lines of march of
armies. It seems to be a disease in the spread of which travel
is especially involved. Cholera epidemics, when once under
control, do not start up again until the disease is brought from
another country by travelers.  Carriers of long duration are so *
rare that they, alone, do not keep the disease alive in a com-
munity. Nevertheless the carrier state is sometimes of long
enuf duration to permit the carrier to remain infectious during a
voyage across the ocean.
   1 Craster, Chas. v.: Ship-borne Cholera. Jour. Amnicon Medical Assoc., Dec. 20
1913, LXI. 2211. Creel, R. H.: Method Employed at New York Quarsntin for the
Detection of Cholera Carriers. Jour. Am. Public Hroflh Assoc.. Dec., 1911, I. 899.


136

infecting food, and the stewards and stewardesses, rf carrrers,
would be likely to infect the passengers to whom they brought

food.

With all these possibilities, the number of outbreaks of T typhoid
                                         __

fever traced to carriers on trains, or ships is small and much
infection is undoubtedly prevented bv the supervision of samtary

arrangements by railroad and steamship companies and health
officials. Pannenborg' has collected reports of typhoid fever
outbreaks, due to carriers, on thr - ree war-vessels-ne Japanese,

and two German.

While sanitary precautions to a degree prevent the spread of
disease on interstate passenger steamers, the conditions on some
of the intrastate lumber and freight boats are ideal for the spread
of typhoid fever from one member of the crew to the others.
An example is furnisht by a carrier in the crew of a lumber steamer
sailing from Humboldt County to San Francisco.2 An in-,
vestigation by the California State Board of Health showed that
this carrier, altho he had nothing to do with the preparation
or serving of food, had spread the infection to 27 sailors and
officers, four of whom had died. Twenty-six of these mfechons
took place during a stay of three years and seven months on one
                                     . .
vessel which carried only 22 men.  The condrtrons on board gave
opportunity for the transfer of infection in the crowded fore-
castle, and in the dirty water closet, but especially by means of a
cask for drinking water. This cask was filled with water in port,
and during the voyage the men dipt drinking water from it with a
common cup, frequently wetting their hands in the process.
Under this arrangement pollution of the water was unavoid-

able.

This carrier was placed under quarantine at the : Ma: rine Hospital
in San Francisco and was studied and treated by officers of the
United States Public Health Service with a view to making it
safe for him to return to his trade.  At the end of seven months
he was releast on parole because the typhoid oacmus nau UUL
  1 See second foot-note on p. 133.
1 Sawyer, W. A.: A Typhoid Carrier on Shipboard. Jour. Am. Med. Assoc.. May
4. 1912. Vol. LVIII, p. 1336.

137

been found in his feces for four months.  He found work on a
lumber vessel and shortly afterward infected three sailors, one
of whom died. An investigation by the officers of the United
States Public Health service showed that this ship, like the
other one, had a drinking cask into which the men dipt a common
cup, wetting their hands as they did so.  Conditions like these
would be serious even in the absence of an unusually dangerous
carrier like the one reported. The drinking water supply on
board a ship should be in a closed container'to avoid contamina-.
tion and should be drawn thm a faucet.

PRECAUTIONS AGAINST INFECTION FROM CARRIl$RS.

The danger from carriers on railroads and steamboats can be
reduced by diminishing the opportunity for transfer of infection
from one person to another and by detecting and controlling the
more dangerous carriers.
"Great advances have already been made in diminishing* the'
opportunity for the transfer of infection to passengers fiom'other
passengers or employees. The interstate quarantine regulations
promulgated by the United States Treasury Department forbid
the providing, by common carriers, of any drinking cup or glass
for common use in cars, ships, or depots. The individual paper
cup on trains and the bubbling fountain in stations have taken the
place of the common drinking glass which used to furnish such an
obvious opportunity for transferring germs from the mouths of
carriers to those of well people. The interstate quarantine regula-
tions forbid also the furnishing, by common carriers, of any towel
for the use of more than one person, thus decreasing the danger
from carriers.  Drinking water is protected from the danger of
contamination by carriers, especially typhoid carriers among
employees, by the regulation that ice shah be handled in such
manner as to prevent its becoming contaminated with disease
organisms. The railroad companies have their own regulations
regarding special buckets and carts for ice and the use of ice tongs
and rubber gloves, all designed to avoid the touching of ice with
hands and to prevent clothing from coming in contact with it.


The danger of the less immediate contacts is diminisht by the
rules of the railroad companies regarding the cleansing of cars,
the changing of the linen covers and head rests, and the cleaning
and disinfecting of toilet rooms.

On passenger ships engaged in interstate traffic, precautions
similar to those of the railroad companies are being taken. It
is in the coastwise steamers which do not carry passengers and
are not interstate carriers that we find conditions very favorable
to the transfer of infection from carriers to other members of the

crew.  On these ships, the storage of water in open casks, acces-
sible to the crew, the use of the common drinking cup, the crowd-
ing of the forecastle, and the use of insanitary toilets are some-
times still found and should be corrected.

The best of sanitary arrangements would not entirely prevent
the danger from carriers on trains and boats.  It is necessary that
the more dangerous carriers should not engage in certain occupa-
tions.  Greatest care must be taken to exclude the typhoid
carrier from service in the kitchen or dining room of steamboat
or train.  The Southern Pacific Company requires that all ap
licants for appointment to positions on trains or in stations shall
be examined physically when admitted to the service and ap-
plicants found to be suffering from any disease that would make
their employment in that service inadvisable are rejected.  With
cooks and waiters there is additional provision for re-examina-
tion on suspicion that they may be suffering from a disease which
would make them dangerous to the traveling public. How far
these examinations protect against the employment of carriers
depends largely on the ability of the examining physician to get at
the facts, in the carrier's past history, which would lead to sus-
picion of his condition.  Laboratory tests could then be made,
but even in the absence of laboratory proof no person with a
very suspicious history should be employed in a position where a
carrier would be dangerous, because many carriers are inter-
mittent in the discharge of their disease germs.

The protection against carriers depends to a large extent on
co-operation between health departments in detecting and keeping
under surveillance dangerous carriers. All outbreaks of com-
            *

139

mm&able disease ahonld be investigated. If carriers are dis-
covered they should .at least be kept from engaging in occupa-
tions in which they would be specially dangerous.  Ifacarrier
moves away from the jurisdiction of the local health officer, the
health 05cer at his point of destination should be officially
notified so that he will be responsible. In this way the danger
from carriers both on and off boats and trains would be dimi&ht, I,