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the reason that they furnish com- The reduction in typhoid fever
plete records. The accompanying for Sandusky is not as marked as
diagrams show graphically the in the cases previously mentioned
effect upon the typhoid fever death and it is believed that this was the
rates due to the introduction of result of improper construction of
filtration of the water supplies. the water purification plant, which
The data for Ashtabula, Cincin- necessitated the use of raw water
nati and Columbus are obvious and from time to time to meet the con-
need no explanation. It will be sumption. An entire new plant was
noted that the rate for Lorain in constructed in 1914 and has been
1892 was only 14. At this time in satisfactory operation since. It
the city obtained untreated water is gratifying to note that during
from Lake Erie, as had been the 1915 and 1916 the rates were main-
case for the previous eight years, tained at 10 per 100,000.
during which time the typhoid rates The Toledo diagram fails to ex-
were not abnormal. In 1892 the hibit any marked reduction in ty-
city installed a system of sanitary phoid fever rates. The city health
sewers, discharging directly into department attributes this to the
the Black River, which enters Lake widespread use of private wells
Erie not far from the old water throughout the city in preference to
supply intake. The effect upon the the public water supply. This de-
water supply is shown by the great moristrates the necessity for univer-
increase in the typhoid fever death sal use of a public water supply
rate which occurred the following after its purification has been ef-
year and continued until 1897,

when filtration of the water supply The Youngstown diagram shows
was provided.

a very marked reduction following

filtration, but it will be noted that resulting saving in life alone will the residual typhoid is much higher fully repay the city for the investthan should be the case. An in- ment required. W. H. D. vestigation of typhoid fever at Youngstown in 1906 led to the conclusion that the use of private wells was the most important single STEUBENVILLE'S SURVEY cause of the disease. In Table 2 results for additional

A recent public health survey of

the city of Steuben ville disclosed Ohio cities are presented. The data

the following facts: for these cities are not complete

That the city water supply is and therefore were not included in Table 1.

good, but that about one thousand They demonstrate,

persons use private water supplies, however, a marked reduction in the

some of which are probably unsafe. typhoid fever death rates following

That a system of city superfiltration.

vision of the milk supply is lacking, The temporary treatment of the

and that sanitary conditions on public water supplies of Cleveland

dairy farms inspected were good and Zanesville, by the use of

in some respects and bad in others. chlorination, has also had an effect!

That insanitary conditions were in lowering the typhoid fever death

present in numerous food-handling rates. At Cleveland, for five years, establishments, over which the city 1906 to 1910, the average rate was exercises no supervision. 16. Chlorination of the water sup- That sewage is discharged withply was undertaken in 1911. For out treatment into the Ohio River five years, 1912 to 1916, following and that several sections of the city chlorination, the average rate has are without sewer facilities. been 8. At Zanesville the average - That the lack of adequate garfor five years prior to 1913 was 75. bage disposal provisions and of In that year chlorination of the

any regulations for stable construcwater supply was started. The

tion encourage fly-breeding. average for three years since 1913 That the staff of the city health has been 31.

department consists of a full-time These examples of the beneficial health officer, who is without effects realized from the improve- medical or public health training; ment of public water supplies are a full-time plumbing inspector and not abnormal cases, and are only a part-time clerk. representative of the general ex- That the department's 1917 experience of cities formerly having penditures amounted to $6,344-45, contaminated water supplies, which more than half of which was for have been replaced by pure sup- quarantine and fumigation, mostly plies. The evidence is so in cases of smallpox. clusive that it may now be predicted The report urged the employwith certainty that a city having ment of a technically trained health an impure water supply and con- officer at a salary of $3.000 to sequently a high typhoid fever $3.500, the establishment of a death rate, may reduce its rate to laboratory and of a dairy and food an important extent by providing inspection system and the installaa pure public water supply and by tion of a public health nursing seryencouraging its general use. The ice.




The Health Officer's Responsibility in

the Prevention of Typhoid Fever



ERY few health officers real- perform his duty in the prevention ize their responsibility in of a disease unless he knows that

the prevention of typhoid the disease exists and where it fever. This is due in part to the exists. A few prosecutions would fact that typhoid fever has not teach wholesome lesson and been declared to be a quarantinable bring about a greater respect for disease and also to the attitude of the law and the rights of others. a great part of the medical profes- While it is not required or necsion who have failed or refused to essary that a case of typhoid fever report cases of the disease to the be quarantined it is necessary that health officer. As evidence of this the source of infection be discovwe have the reports of cases as re- ered and this is the function of the turned to the State Department of health officer. The individual Health and the certificates of physician has a concern in caring deaths returned to the Bureau of for the patient and protecting other Vital Statistics. During 1917 members of the family from infecthere were reported 3,127 cases and tion from the patient but the health 682 deaths from typhoid fever, officer cannot expect that this making a

case fatality rate of physician is going to make the nearly 22 per cent. The probable thorough investigation that will number of cases of this disease in disclose the source of infection. Ohio last year was in the neighbor- There is no health officer in Ohio hood of 10,000, and this would in- who was selected solely because of dicate that less than one-third of his ability in discovering the source all cases were reported.

of infection in communicable disTyphoid fever is now and has ease, and from experience we know been for many .years a reportable that a great many health officers disease; just as much so as small- when appointed did not know even pox, diphtheria and other diseases the fundamentals of such investiwhich must be quarantined. A gations, but this does not mean physician who fails to report is

that every man who accepts the ofliable to prosecution and on convic

fice of health officer is not legally tion to pay a fine. A second of- and morally obligated to learn this fense is punishable by fine and also essential part of his work. imprisonment. We have no record It is the duty of the state to proof an Ohio physician being pros- tect the health of the citizens of ecuted for failing to report typhoid the state. To forward this work, fever but it is self-evident from the legal obligation has been laid the figures given that there should upon each municipality and townhave been many prosecutions and ship to establish a board of health it is the fault of health officers if or some agency to act in lieu of a this has not been done. It is ob- board of health and powers and vious that a health officer cannot duties have been conferred upon or




required of each such board or cause of the difficulty in making agent. In these powers, which in diagnosis in obscure cases but the reality are duties, is found the au- physician must learn, what so thority to "make such orders and

many seemingly have not learned, regulations as it (the board of that a communicable disease is nothealth) deems necessary for its an individual or familyproblem own government, for the public but is a matter of great public conhealth, the prevention or restriction cern, and that in all matters that of disease, and the prevention, directly affect the public the rights abatement suppression and wishes of the individual must nuisances."

give way to the rights of the public. The authority to make regula

The secondary and a greater retions to prevent and restrict the sponsibility rests with the health spread of disease gives a board of authorities. If reports of cases are health the opportunity to institute not made by physicians, legal measmeasures to control any disease ures must be used to secure comthat can be communicated from pliance with the law. When a reone person to another or from port is made an immediate investian animal


human being. gation must follow to discover the These regulations do not define source of infection. Not one but or limit the obligations of the all possible sources of infection board of health but prescribe the must receive attention. Sending a general rules and methods that sample of water to the state laboraare to be enforced and followed by tory for examination does not rethe board of health and its em

lieve the health officer of the necesployes in pursuance of this obliga- sity of investigating the milk suption.

Relief from the obligation ply, possible contact with can only be complete when every- previous case, fly infection, etc. It thing has been done that can be does not relieve him of his duty done to prevent the spread of

to see that the excreta of the disease and to render aid where, patient are thoroughly disinfected by positive injunction of law, as

before being thrown into a privy, sistance must be given to the sick buried or otherwise disposed of. and to those shut in because of Each case of typhoid is the possible having been exposed.

beginning of an epidemic and the The primary responsibility in the health officer who, by his failure to prevention of typhoid fever must act, permits the occurrence of secrest with the physician. If he ondary cases is assuming a responrecognizes the nature of the disease sibility that some day, perhaps, will and does not report, or if he sus

place him in a more than unenviapects the case to be typhoid and ble position in his community. does not use every facility at hand

J. E. B. to assist him in making a diagnosis, or if he does not give directions for procedures to prevent further


diseases utilize the infection, he must assume full re- mucous membrane of the nose and sponsibility for his failure to act. throat and gain a foothold in the Due allowance must be made be- body." - Flexner.


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