curs occasionally in cases of paratyphoid, especially if the blood has not been diluted sufficiently and in the cases of persons who have received preventive typhoid inoculation or who have recently had typhoid.

In interpreting results, therefore, it is important for the physician to know whether the patient has had typhoid previously or has been vaccinated against typhoid. After an attack of typhoid, agglutinins persist in the blood for about two years, so that an examination made within this period is of little value as a diagnostic measure. The

same statement holds true in cases of vaccinated persons. Agglutinins are not as a rule detected in the blood until the fifth day and often not until the tenth. Consequently, the result of an examination made before the fifth or seventh day has very little significance.

This phenomenon may be observed either under the microscope or in a test tube with the naked eye. The former is the method used in most laboratories.

Another way in which the laboratory has proved its value in combating typhoid is in ascertaining the source of infection. It has been well established that the typhoid bacillus is transmitted directly through water, milk and other foods, such as uncooked vegetables and oysters, through flies and through the so-called carriers. It is almost impossible to detect the typhoid organism itself in water. However, if there is typhoid present the water is also almost certainly contaminated with excreta. As all excreta contain members of the colon group the detection of this organism in water indicates pollution and there is strong probability that such water

may also contain the typhoid bacillus. Many epidemics have been definitely traced to a polluted water supply. The pollution is usually near by and there is a direct transfer of fresh infection. Samples of all water which is used for drinking purposes and regarding which there is any suspicion should be sent to the laboratory to determine the presence of pollution, and the water should be considered unsafe for use if samples are found to be contaminated. No other single

measure in reducing typhoid fever in cities has met with such success as substituting a safe water for a polluted supply.

Many outbreaks of typhoid fever have been due to milk infected either directly with typhoid excreta or by polluted water used in rinsing cans or other utensils. In many instances the presence of typhoid infection in milk has been traced to "typhoid carriers" employed in the handling of the product.

Milk is a favorable medium for the growth of typhoid organisms, which multiply rapidly in it. It is with great difficulty that typhoid is isolated from milk and the milk responsible for an epidemic is seldom available for analysis. However, the source of infection in milk epidemics may be determined indirectly through laboratory methods.

Some epidemics have been traced to the eating of raw oysters. It was discovered that these oysters had been planted in polluted streams, a method which some oyster men practice to fatten their product. Oysters suspected of coming from such streams should be examined for the presence of the colon bacillus, which indicates such contamination.

The fact that persons who have

suffered from an infectious disease may continue to harbor the organisms of the disease after apparent recovery from it has long been recognized. Investigations have shown that about four percent of the recovered cases of typhoid remain "carriers" for varying lengths of time, some even for years. So-called healthy carriers give off virulent organisms in their feces and urine in enormous numbers. These carriers are a source of the greatest danger. Many cases of typhoid have been traced to cooks in restaurants and private families. Some cooks have become notorious on account of the trail of typhoid they have left behind them. Fortunately the presence of typhoid in excreta can be demonstrated by laboratory methods. The excreta of all typhoid convalescents engaged in the handling of food stuffs should be submitted for bacteriological examination and proved to be free from typhoid infection before such persons are allowed to resume their former occupations. give off typhoid organisms only intermittently, two or more examinations should be required. Specimens should be examined within a few hours after they are taken, or where this is impossible specimens of stools should be sent to the laboratory in twenty percent glycerine and saline.

As many carriers

The method of detecting the organism in excreta consists in plating the material on special differential media, and isolating suspicious colonies. These are subsequently confirmed by cultural and agglutinin tests. Where a number of people are under suspicion of being carriers, specimens of the blood are usually taken and submitted for the Widal reaction. As

carriers generally give a positive Widal test it greatly facilitates matters to examine the excreta of those giving the positive reaction first, in order to detect the carriers. Even after long and heroic treatment many individuals still continue to have the organisms and offer a most perplexing problem to health authorities.

One of the important means in preventing the spread of typhoid fever is the use of vaccines. In 1896 Pfeiffer and Kolle tried the effect of giving human beings small injections of typhoid bacilli. It was discovered that a few doses had the effect of producing agglutinins in the blood of these individuals, which indicated that they were probably protected against typhoid fever. At the same time Wright began injecting British soldiers who volunteered for the purpose. Today all the soldiers of the world are given protective inoculations of typhoid vaccine. The present world war has demonstrated without question the value of typhoid vaccination. During the Franco-Prussian war sixty percent of all deaths were due to typhoid. Today in both the German and Allied armies typhoid is extremely rare. During our own Spanish-American War there were seven times as many deaths from typhoid as from bullets. One-fifth of the enlisted men contracted the disease. In 1912 vaccination was made compulsory in the United States Army, with the result that there developed only twenty-seven cases that year. In the following year this number was reduced to four. Today, although we have over two million men under arms, the weekly reports from the surgeon general's office show no cases of typhoid. This disappearance of

typhoid from the army cannot be attributed only to improvements in sanitation, as outside the army camps the men are subject to the same conditions as in civil life, where typhoid still prevails extensively.

Several methods of making and administering typhoid vaccine are in use. At the present time the use of a single strain is generally employed, three three injections being given. In the United States Army this method has produced superior results. Some workers use several strains in combination in order to insure protection against the possibility of several types existing. Others also consider it advisable to combine the typhoid with the paratyphoid strains in order to protect against paratyphoid fever, which is very similar to typhoid. Whatever method is used, the inoculation produces in the individual usually only a discomfort which lasts but a few days. Some persons are entirely unaffected. Serious or permanent results probably never follow the inoculation.

The laboratories of the Ohio State Department of Health manufacture typhoid vaccine and distribute it to physicians free of charge upon request. This vaccine is made according to the methods of the United States Hygenic Laboratory. Only one strain is employed, care being taken to secure one that produces strong agglutinin s. This property is regarded as most essential. The vaccine consists of an emulsion of the typhoid bacillus killed by heat. The emulsion is so diluted that the doses consist of about five hundred million and one billion organisms respectively. Each dose is placed in an ampoule and preserved with tricresol. The finished product is

tested by animal inoculations and cultural methods for the presence of other living organisms, especially tetanus.

Typhoid fever is still a disease of the greatest significance, ranking fourth among the diseases causing death and disability. There are encouraging prospects, however, that this foe of human life can be entirely abolished, and certainly the laboratory will play no mean part in accomplishing this end.

R. V. S.

Whooping Cough Strikes Heavily The dangers of whooping cough to young children were again brought to notice in two news items which appeared within a few days of each other last month. One told of the death of three children from the disease within two days in Tiffin, the second told how the disease had taken two children from each of two Columbus households in two successive days and the third told of still another death in Tiffin.

Lima Regulates Barber-shops

Sanitary methods in barbershops are required under regulations recently passed by the Lima board of health. board of health. The regulations were drawn up by the barbers themselves, acting through their union. Regular inspections are to be made of all shops. A permit from the board of health must be obtained by anyone desiring to operate a barber-shop. All instruments must be sterilized after each time used and no powder-puffs or sponges may be used.

HEN one studies the re

W ports of typhoid fever

which come to the State Department of Health one is struck by the number of cases which occur in families in which there have previously been cases of the disease. The usual history of these cases is that of a first case, contracted perhaps away from home, which is followed after a couple of weeks by another case, evidently contracted from the first case, and frequently even by other cases, until sometimes the whole family is stricken one after another.

These secondary cases are practically always unnecessary and easily preventable. Typhoid fever is not contagious like measles or scarlet fever, in that one may contract it by simple bodily contact with a previous case. It is contracted only when some of the germs from the body of the patient are actually introduced into the mouth of a well person. This sort of infection may be prevented by care on the part of those who have the nursing of the case.

To prevent the spread of typhoid from a case the first care should be to disinfect the discharges from the bowels and bladder of the case. These discharges are the principal source of the infection and constitute the greatest danger. Even if the discharges are carefully disinfected, however, there is danger that the hands of the attendant may have become soiled. The nurse, or other person attending

the case should, therefore, disinfect her hands by washing with soap and water, soaking them in disinfectant and then rinsing in clean water every time she performs any service for the patient, and always before leaving the sickroom to go to any other part of the house.

The dishes from the sickroom should always be placed in a separate pan and boiled before being handled. They should be entirely separate from those used by others of the household.

The bed and body linen of the patient should likewise be put into a wash boiler, covered with water and boiled before being handled by anyone outside the sickroom.

In view of the fact that these precautions require great care and vigilance for success, it is well for those who are called on to nurse a case of typhoid, or who live in a house where there is a case, to protect themselves still further by submitting to typhoid vaccination. The process is not dangerous and causes only slight disturbance in most cases, and it affords very great protection against the disease.

The carrying out of the precautions outlined above, by those who are immediately in contact with cases of typhoid fever would save several hundreds of cases in Ohio every year.

Good health at home is as important a factor in the war as good health in the field.