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 ty phoid 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. As many carriers 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.

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.

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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. 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. 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 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 agglutinins. 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

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HEN one studies the reports 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.

particular group in the classification followed by the survey cities of from 300,000 to 500,000 population-Cincinnati stands second only to Newark, N. J.

Cleveland is fifth among the nine cities with more than 500,000 population. Lower rates than Cleveland's are reported in Chicago, Boston, New York and Philadelphia. Cleveland was ahead of Philadelphia in 1916. Regarding the slight rise which is seen in Cleveland's 1917 rate, the Journal remarks: "The chlorination of the Cleveland water continues to prove a source of trouble and complaint. Early in the year the chlorine dosage was materially reduced against the protest of the city health authorities. It is possible that the slightly increased typhoid rate * * * may be connected with this action."2

Columbus is ranked seventh among the ten cities of from 200,000 to 300,000 population. Cities with better records, in this group, are: St. Paul, Rochester, Jersey City, Denver, Providence and

Portland, Ore. Columbus' rank in the group was ninth in 1916.

Toledo rose from eleventh place in 1916 to ninth place in 1917 among the fourteen cities in the 125,000-200,000 group. It was outranked last year by Oakland, Worcester, Scranton, Syracuse, Omaha, Richmond, Spokane and New Haven.

Dayton, the only Ohio city with a rate of more than 10.0, was fifth from the bottom of the cities from 100,000 to 125,000 in 1917. Salt Lake City was the only nonSouthern city in this group with a rate higher than Dayton's. Dayton was sixth from the bottom of this group in 1916, but her 1917 rate, it will be noted by reference to the table, showed a slight improvement over the 1916, even though her relative position dropped. In the entire list of sixty cities, the only cities outside the South with higher rates than Dayton's were Baltimore, Fall River, Detroit and Salt Lake City. Seven Southern cities also had lower rates than Dayton.