2,658

2,748

23.2

3,871

15.5

1903.

3,671

2,342

4,326

1,867

15.1

11

14.4

3,467

4,426

19.0

234

37

15.1

119

11

14.1

3,582

198 12.4

215

39

15.1

81

11

13.6

3,450

11

12.3

2.2

6.4

146

24

6.2

39

4

4.0

The Department publishes a quarterly statement in its Weekly Bulletin of typhoid, showing the number of cases, Widal examinations, secondary cases, out of town infections, and immunications of the exposed persons in connection with reported cases. These are summarized for the entire year for the reader's convenience.

Manhattan. Bronx. Brooklyn. Queens. Richmond. City.

The out-of-town cases, probable and possible, amount to 15% of all reported The secondary or direct contact cases constitute 7%.

cases.

Some Special Outbreaks in Recent Years.

East Side, 1913.—A word may be said regarding the outbreak of typhoid fever in 1913 on the lower East Side of Manhattan, in a district reaching from 40th Street to the Southern limits of the city and embracing a population of nearly 600,000. There were 521 cases, with 61 deaths, a case fatality of 11.7%. The first group of cases was reported on September 2nd. It was soon found that the majority of the patients had used a raw milk supplied by the same company, and as one of the many creameries belonging to the company was mentioned in connection with nearly all of them, this milk was excluded from the city with the result that, in two weeks from the time of exclusion, the number of daily cases reported fell off rapidly. Had the early cases been promptly reported many of the later ones would have been prevented. There were, as usual, a large number of secondary infections occurring after the original source of infection was removed, so that the total time of the increased incidence in this section covered a period from September to November, inclusive.

Upper West Side, 1914.-In April and May, some 30 cases were reported in Manhattan, from the neighborhood of 108th to 110th Streets. No common source

of food was discovered and the Department was at a loss to determine the origin of the infections. The families involved had purchased vegetables at various neighboring markets. A search for a carrier among the dealers brought to light a "Widal-positive reaction in the case of the wife of one of them. She was excluded from service until a number of her stools and samples of her urine were examined and found free from typhoid bacilli. After an interval, she was re-examined with similarly negative results. She is being kept under observation.

Hart's Island, 1914.-In August and September, 1914, 39 cases of typhoid fever were reported from Hart's Island among the prisoners in the workhouse and reformatory, with two deaths, the majority of the cases being the older men in the workhouse. A diligent but unsuccessful search was made in the kitchen and the pantry for a carrier and the food habits were carefully gone over. Except for a few cases, which from their onsets may have been secondary infections, the patients had eaten raw clams gathered on the beach. This was contrary

to the rules of the institution, but it was a difficult thing to prevent as men performing certain duty were necessarily about the beach and could easily secure the shell fish and in some instances secrete and pass them on to others.

The Commissioner of Corrections gave the Health Department every facility for studying the outbreak. The resident physician and wardens assisted the investigators freely. The sanitary arrangements were found satisfactory in and about the buildings. One pipe was found to be unsubmerged during very low tide. This was extended to beyond low tide water.

The danger from eating these clams was impressed on the prisoners by Dr. Levy, the resident physician. All the inmates were immunized and arrangements were made to give similar injections to future admissions. In some instances, the first doses were given prior to the transfer to the island. These measures checked the outbreak.

The Sloane Hospital for Women, 1915.-In January and February of 1915 a sharp outbreak of typhoid fever took place in the Sloane Hospital, principally among the nurses, doctors and help. Only one of the 125 or more patients came down and as her onset was among the later ones, it seemed as though her infection was due to contact rather than exposure to the original source of the outbreak. There were in residence during the period about 75 paid help, together with 73 nurses and 8 doctors. Among these help, 10 of the nurses and 4 of the doctors. who contracted the disease, made 25 in all. only took one meal in the institution.

The onsets were distributed as follows:
Jan. 11th-Physician (one meal only)

Jan. 6th.

Jan. 14th-Nurse.

Jan. 15th-Physician.

Jan. 16th-Nurse.

Jan. 18th-Physician.

Jan. 20th-Elevator man.

Jan. 22nd-Nurse.

Jan. 24th-Patient. Left hosp. Feb. 9.

Jan. 24th-Waitress.

Jan. 25th-Nurse.

Jan. 26th-Waitress.

typhoid fever developed in 10 of the These, with the patient in residence One of the doctors was a visitor and

Jan. 27th-Waitress.
Jan. 27th-Cleaner.
Jan. 28th-Chambermaid.
Jan. 29th-2 nurses.
Jan. 29th-Waitress.

Jan. 31st-Nurse.

Feb. 1st-1 nurse.

Feb. 1st-1 chambermaid.

(Ambulatory for time.)

Feb. 5th-Physician.

Feb. 20th-Porter (uncertain case),

Careful search was made by the Hospital authorities and by the Health Department for an outside contamination of the food supply. The milk was of a high grade and pasteurized, and others in various portions of the city, receiving the same supply, were not contracting typhoid fever. A thorough search was made by the Department in the creamery and pasteurizing plant of the Company and all histories and specimens were found negative. Widal examinations were also made of the serum of various persons handling the vegetables used. Nothing was found. A bacteriological analysis performed by the hospital of the filtered water used also yielded negative results.

Widal and faecal specimens were taken from all of the kitchen and pantry force, some of them being examined in the laboratory of the College of Physicians and Surgeons, and others in the Health Department Laboratory. All specimens were negative, except one Widal faintly positive in the case of the cook, who gave a history of typhoid fever some years ago. She was, of course, excluded from active service. Three faecal specimens were at once examined in her case by the institution, none of which showed the presence of typhoid bacilli. She left the premises on a few hours' leave and failed to return or to give her. address. There were at this period three prominent features in connection with the study of the situation:

1st-24 of the 25 cases occurred among the 156 doctors, nurses and employees; while only one infection took place among the 125 or more patients in the hospital at the time.

2nd-One of the doctors infected took only one meal in the institution and that on the evening of Jan. 6th. The date of this meal could not be obtained from him until he had made sufficient improvement to be interviewed.

3rd-The cook exhibited a faintly positive Widal reaction and had a history of typhoid fever an indefinite number of years previously.

Item 2 prompted a careful study of the hospital menu for the evening of January 6th. A gelatin dessert containing fruit was served at this meal with whipped cream. The physicians and nurses and at least some of the help partook of this gelatin, which was prepared on Wednesday morning in the usual way and allowed to cool, and was served at the evening meal. The gelatin, if infected with the typhoid bacilli, would afford a good culture medium. A final conclusion required further analysis of the excreta of the cook. After much difficulty, she was located and two stools were obtained which were found to contain typhoid bacilli. These samples were procured in the most cautious manner; they were submitted by her under an assumed name while she at the same time believed she was eluding the Health Department. Through indirect channels, it was learned that she was engaged as a cook in an inn in New Jersey, beginning Jan. 6, 1912, where the superintendent's wife was taken ill with typhoid fever on March 21st of the same year; two other cases developed among the help in the following May and July. She continued there, with a month's interval on vacation, until June 26th of 1913. On July 1, 1914, she returned to this place, remaining for only a brief interval during which two of the village children who took meals frequently in the kitchen contracted the disease. Specimens were then taken for the Widal examination from all employed at the inn. These were negative, but the procedure disturbed the cook very much and she left the place. Her whereabouts since then have been traced and her connection with other cases is being investigated. Her engagement at the Sloane Hospital began

October 17, 1914. At about this time, she seems to have conveyed the disease to another person outside the hospital. A man connected with the employment agency, through which this woman procured her place, had suffered from an indigestion of long standing. This cook prepared for him a home remedy for internal use, and, a few days later, he came down with typhoid fever and was taken to Hahnemann Hospital.

While under observation the woman behaved in a remarkable manner; her actions aroused suspicion that she might have had some similar previous experience and as she appeared to have an abnormal fear of the Health Department it was surmised that she might be the well-known Mary Mallon (Typhoid Mary). She was identified as such, followed to her residence and taken into custody. She is now at Riverside Hospital, where she will remain for an indefinite period.

This bacillus carrier is already well known in medical literature through the studies of George A. Soper, Ph.D., connecting her with no less than seven outbreaks of typhoid fever involving 26 cases in a period of seven years. To this must now be added the twenty-five cases at the Sloane Hospital, the five in New Jersey, and the one referred to as infected through the domestic remedy, making in all fifty-seven cases. Of these, three died.

The foregoing facts in her history are well authenticated. The Department is now engaged in following up another interesting suggestion, namely that the well-known water-borne outbreak of typhoid fever in Ithaca, N. Y., in 1903, embracing over 1,300 cases, was initiated by infection from a typhoid carrier acting as cook. The Department has been informed that a person by the name of Mary Mallon was employed as cook in the vicinity of the places where the first cases appeared. The circumstances of the outbreak permit the supposition that this subsequently resulted in the contamination of the water supply.

Outbreaks such as the one at the Sloane Hospital, and the others for which she is known to be responsible, show the advisability of making the agglutination test on applicants for positions in the kitchens and pantries of institutions, hotels, and restaurants. While the serum of a carrier does not always yield a positive Widal reaction, it takes place in about 75% of such persons and is therefore a valuable index. The specimen is easily taken, substitution is eliminated, and the result of the analysis is soon available. This practice is being followed in some institutions. Columbia University recently required an entire restaurant staff on its premises to submit to this test, and proposes to have all future applicants for positions tested in this way.

Carriers.

Robert Koch, in 1902, laid stress on the typhoid convalescent as the most fruitful source of further infection, and, "at his recommendation, bacteriological stations were instituted in the typhoid ridden districts, notably in southwest Germany, for the the purpose of testing in actual practice the validity of his dictum that the chief source of infection is to be found in man himself" (Ledingham and Arkwright). Through these agencies it was discovered that persons apparently healthy could not only harbor the bacilli, but could continuously or periodically emit them, thus becoming "carriers" and distributors. Two types are manifest; the temporary, "in whom the excretion ceases before the end of the third month, and the chronic, excreting for an indefinite period." (Sacquepee, 1910.)