the reason that they furnish complete records. The accompanying diagrams show graphically the effect upon the typhoid fever death rates due to the introduction of filtration of the water supplies. The data for Ashtabula, Cincinnati and Columbus are obvious and need no explanation. It will be noted that the rate for Lorain in 1892 was only 14. At this time the city obtained untreated water from Lake Erie, as had been the case for the previous eight years, during which time the typhoid rates were not abnormal. In 1892 the city installed a system of sanitary sewers, discharging directly into the Black River, which enters Lake Erie not far from the old water supply intake. The effect upon the water supply is shown by the great increase in the typhoid fever death. rate which occurred the following year and continued until 1897, when filtration of the water supply was provided.

The reduction in typhoid fever for Sandusky is not as marked as in the cases previously mentioned and it is believed that this was the result of improper construction of the water purification plant, which necessitated the use of raw water from time to time to meet the consumption. An entire new plant was constructed in 1914 and has been in satisfactory operation since. It is gratifying to note that during 1915 and 1916 the rates were maintained at 10 per 100,000.

The Toledo diagram fails to exhibit any marked reduction in typhoid fever rates. The city health department attributes this to the widespread use of private wells throughout the city in preference to the public water supply. This demonstrates the necessity for universal use of a public water supply after its purification has been effected.

The Youngstown diagram shows a very marked reduction following

filtration, but it will be noted that the residual typhoid is much higher than should be the case. An investigation of typhoid fever at Youngstown in 1906 led to the conclusion that the use of private wells was the most important single cause of the disease.

In Table 2 results for additional Ohio cities are presented. The data for these cities are not complete and therefore were not included in Table 1. They demonstrate, however, a marked reduction in the typhoid fever death rates following filtration.

The temporary treatment of the public water supplies of Cleveland and Zanesville, by the use of chlorination, has also had an effect in lowering the typhoid fever death rates. At Cleveland, for five years, 1906 to 1910, the average rate was 16. Chlorination of the water supply was undertaken in 1911. For five years, 1912 to 1916, following chlorination, the average rate has been 8. At Zanesville the average for five years prior to 1913 was 75. In that year chlorination of the water supply was started. The average for three years since 1913 has been 31.

These examples of the beneficial effects realized from the improvement of public water supplies are not abnormal cases, and are only representative of the general experience of cities formerly having contaminated water supplies, which have been replaced by pure supplies. The evidence is so clusive that it may now be predicted with certainty that a city having an impure water supply and consequently a high typhoid fever death rate, may reduce its rate to an important extent by providing a pure public water supply and by encouraging its general use. The

con

A recent public health survey of the city of Steubenville disclosed the following facts:

That the city water supply is good, but that about one thousand persons use private water supplies, some of which are probably unsafe.

That a system of city supervision of the milk supply is lacking, and that sanitary conditions on dairy farms inspected were good in some respects and bad in others.

That insanitary conditions were present in numerous food-handling establishments, over which the city exercises no supervision.

That sewage is discharged without treatment into the Ohio River and that several sections of the city are without sewer facilities.

That the lack of adequate garbage disposal provisions and of any regulations for stable construction encourage fly-breeding.

That the staff of the city health department consists of a full-time health officer. who is without medical or public health training; a full-time plumbing inspector and a part-time clerk.

That the department's 1917 expenditures amounted to $6,344-45, more than half of which was for quarantine and fumigation, mostly in cases of smallpox.

The report urged the employment of a technically trained health officer at a salary of $3,000 to $3,500, the establishment of a laboratory and of a dairy and food inspection system and the installation of a public health nursing service.

V

ERY few health officers real

ize their responsibility in the prevention of typhoid fever. This is due in part to the fact that typhoid fever has not been declared to be a quarantinable disease and also to the attitude of a great part of the medical profession who have failed or refused to report cases of the disease to the health officer. As evidence of this we have the reports of cases as returned to the State Department of Health and the certificates of deaths returned to the Bureau of Vital Statistics. During 1917 there were reported 3,127 cases and 682 deaths from typhoid fever, making a case fatality rate of nearly 22 per cent. The probable number of cases of this disease in Ohio last year was in the neighborhood of 10,000, and this would indicate that less than one-third of all cases were reported.

Typhoid fever is now and has been for many years a reportable disease; just as much so as smallpox, diphtheria and other diseases which must be quarantined. A physician who fails to report is liable to prosecution and on conviction to pay a fine. A second offense is punishable by fine and also imprisonment. We have no record of an Ohio physician being prosecuted for failing to report typhoid fever but it is self-evident from the figures given that there should have been many prosecutions and it is the fault of health officers if this has not been done. It is obvious that a health officer cannot

perform his duty in the prevention of a disease unless he knows that the disease exists and where it exists. A few prosecutions would teach a wholesome lesson and bring about a greater respect for the law and the rights of others.

While it is not required or necessary that a case of typhoid fever be quarantined it is necessary that the source of infection be discovered and this is the function of the health officer. The individual physician has a concern in caring for the patient and protecting other members of the family from infection from the patient but the health officer cannot expect that this physician is going to make the thorough investigation that will disclose the source of infection.

There is no health officer in Ohio who was selected solely because of his ability in discovering the source of infection in communicable disease, and from experience we know that a great many health officers when appointed did not know even the fundamentals of such investigations, but this does not mean that every man who accepts the office of health officer is not legally and morally obligated to learn this essential part of his work.

It is the duty of the state to protect the health of the citizens of the state. To forward this work, the legal obligation has been laid upon each municipality and township to establish a board of health or some agency to act in lieu of a board of health and powers and duties have been conferred upon or

required of each such board or agent. In these powers, which in reality are duties, is found the authority to "make such orders and regulations as it (the board of health) deems necessary for its own government, for the public health, the prevention or restriction of disease, and the prevention, abatement or suppression of

nuisances."

The authority to make regulations to prevent and restrict the spread of disease gives a board of health the opportunity to institute measures to control any disease that can be communicated from one person to another or from an animal to a human being. These regulations do not define or limit the obligations of the board of health but prescribe the general rules and methods that are to be enforced and followed by the board of health and its employes in pursuance of this obligation. Relief from the obligation can only be complete when everything has been done that can be done to prevent the spread of disease and to render aid where, by positive injunction of law, assistance must be given to the sick and to those shut in because of having been exposed.

The primary responsibility in the prevention of typhoid fever must rest with the physician. If he recognizes the nature of the disease and does not report, or if he suspects the case to be typhoid and does not use every facility at hand to assist him in making a diagnosis, or if he does not give directions for procedures to prevent further infection, he must assume full responsibility for his failure to act. Due allowance must be made be

cause of the difficulty in making. diagnosis in obscure cases but the physician must learn, what so many seemingly have not learned, that a communicable disease is notan individual or family. problem but is a matter of great public concern, and that in all matters that directly affect the public the rights and wishes of the individual must give way to the rights of the public.

The secondary and a greater responsibility rests with the health authorities. If reports of cases are not made by physicians, legal measures must be used to secure compliance with the law. When a report is made an immediate investigation must follow to discover the source of infection. Not one but all possible sources of infection must receive attention. Sending a sample of water to the state laboratory for examination does not relieve the health officer of the necessity of investigating the milk supply, possible contact with previous case, fly infection, etc. It does not relieve him of his duty to see that the excreta of the patient are thoroughly disinfected before being thrown into a privy, buried or otherwise disposed of. Each case of typhoid is the possible beginning of an epidemic and the health officer who, by his failure to act, permits the occurrence of secondary cases is assuming a responsibility that some day, perhaps, will place him in a more than unenviable position in his community.

J. E. B.

a

"Many diseases utilize the mucous membrane of the nose and throat and gain a foothold in the body." Flexner.