or other acute infections, tubercular and, rarely, syphilitic meningitis, have to be differentiated. Diagnosis may usually be determined by examination of spinal fluid, that of epidemic meningitis being as a rule, cloudy or purulent and microscopical examination revealing the presence of polymorphonuclear leukocytes and of meningococci. It occasionally happens that the fluid is found to be clear or that the presence of meningococci cannot be demonstrated. Under these conditions when epidemic meningitis is prevailing, if prominent symptoms of meningitis are present, and meningococci can be demonstrated in the nasopharyngeal secretions, diagnosis of this disease is justified.

Two principal types of meningococci, with a number of intermediate types, have been distinguished, the same type invariably existing in the nasal secretions and spinal fluid of the patient, when present in both.

When lumbar puncture reveals a turbid fluid, this should be regarded as presumptive evidence of meningococcus infection, and serum should be administered at once, if available, preferably without withdrawing the needle. If microscopic examination subsequently shows that the condition is due to other pathogenic organisms no harm will have been done to the patient. The usual dose is 30 c. c. for adults and corresponding amounts for children. Following the first dose, two or more successive doses should be administered at 24-hour intervals, irrespective of apparent favorable results from the first doses. A case of moderate severity will require from four to six doses. If of marked severity, or if the case has come under treatment late, serum should be given at 12-hour intervals, up to six to ten doses. In exceptional cases, doses of 40 c. c. or even 60 c. c. may be given. Administration of serum should usually continue until temperature has been normal for at least two days, to avoid relapse.

Withdrawal of spinal fluid should always precede injection of serum. It is advisable to remove a volume of fluid from 2 c. c. to 5 c. c. greater than that of serum injected. In sensitive patients it may be advisable to resort to local anesthesia and in special instances among adults, general anesthesia may be justifiable. Fluid withdrawn should be received in a sterile container and subjected to microscopical examination.

Lumbar puncture should be performed under strictly aseptic precautions, with the patient upon his side, and the back arched. The notch nearest a line connecting the crest of the ilia should be selected, the needle being introduced in the midline and pushed forward and a little upward. Fluid should be allowed to flow until only three or four drops come in a minute. Serum, warmed to body temperature, should then be introduced slowly by gravity, using a funnel or the barrel of a syringe. A sterilized rubber tube, long enough to permit the funnel to be raised twelve inches, should connect the funnel with the needle.

The injection of horse serum into the meninges is always followed by a transient leukocytosis. Considerable reaction with increased temperature, and turbidity of the spinal fluid may occur immediately following injection. This should not occasion anxiety as the ultimate result is a decided clearing of turbid and even purulent fluids, and, as a rule, improvement in the patient's condition.

In from one-third to one-half of the cases treated with serum, on the eighth to tenth day symptoms of serum disease "— fever, skin eruptions,

pain in the joints, digestive disturbances, etc., appear. Under these conditions reinjection of serum should be avoided if possible. In the event of relapse, with recurring turbidity of the spinal fluid, serum in most instances should again be administered.

Preventive measures

During an outbreak most of those who develop the disease are carriers for varying periods before becoming ill. Success in controlling an outbreak depends upon detection and control of all contact carriers. The meningococcus may be readily identified if cultures from the nose and throat can be prepared upon special media and delivered immediately to a laboratory equipped for the purpose. If cultures are delayed in transmission to the laboratory, the results will be uncertain and dangerous carriers may be missed. Specific vaccines have proved of doubtful value as a preventive. In the event of a threatened outbreak, the local health officer should immediately communicate by telephone or telegraph with the sanitary supervisor of his district or the State Department of Health. If the occasion demands, the Department's epidemiological force will be placed at his disposal.

Specific duties of the health officer

1 Isolate suspected cases pending diagnosis.

2 Immediately isolate each case.

3

conditions permit.

Remove to an isolation hospital if

If isolated upon the premises, post a communicable disease placard near the entrance to the house or apartment.

4 Report immediately to the State Department of Health by card and if upon a dairy farm, also by telephone or telegraph.

5 If necessary laboratory facilities are at hand, arrange to have cultures made from the nasopharyngeal secretions of those who have been in contact with the patient and isolate all showing positive cultures. Contacts with negative cultures may be released but should be kept under observation for at least two weeks.

5a The report of an examination showing meningococci in the secretions should be confirmed by sending subcultures to the State Laboratory in Albany.

6 If in doubt as to what course to pursue, communicate immediately by telephone or telegraph with the sanitary supervisor of your district or the State Department of Health.

7 Notify every family or individual in the house of the existence of the disease, and supply each with circulars of instructions. See that those who come in contact with the patient receive and understand detailed instructions regarding the destruction or disposal of articles soiled with nasopharyngeal secretions; methods of disinfection in connection with the care of the patient, and conditions of quarantine.

8

As soon as a diagnosis is made, see that a supply of antimeningococcus serum is secured. An emergency supply may be obtained from the following: The State Laboratory, 278 Yates street, Albany, N. Y.; Steuben County Laboratory, Corning, N. Y.; Laboratory, City Depart

ment of Health, Jamestown, N. Y.; Warren County Laboratory, Glens Falls, N. Y.; Ontario County Laboratory, Canandaigua, N. Y.; Bureau of Health Laboratory, Syracuse, N. Y.; Madison County Laboratory, Oneida, N. Y.; Genesee County Laboratory, Batavia, N. Y.; Buffalo Health Department, Buffalo, N. Y.; Christiance-Dudley Pharmacy, Ithaca, N. Y.; City Health Bureau, Newburgh, N. Y.; City Laboratory, Poughkeepsie, N. Y.; Saranac Laboratory, Saranac Lake, N. Y. As the supply at these stations is limited, when a positive bacteriological diagnosis has been made, telegraph for a fresh supply to Dr. W. C. Noble, Branch Laboratory, 338 East 26th street, New York City. 9 Adults should be permitted to enter and leave quarantined premises only when there is no contact with patient or attendants, and when positive that they will neither handle foods nor come in contact with children.

10 Prohibit public funerals.

(As noted under Reg. 53, Chap. II, the object

of this regulation is to prevent spread of the disease by carriers.)

11 Use all diligence to discover unreported cases.

Recently, new rules and regulations for the control of typhoid and diphtheria carriers have been prepared and approved. Copies of each follow.

TYPHOID CARRIERS

The persistence of typhoid bacilli in the intestinal discharges and urine of persons recently recovered from typhoid fever is not unusual and does not necessarily denote a carrier state. Only in those cases in which the organisms do not disappear from the discharges after twelve weeks may a chronic carrier condition be said to exist. The number of chronic carriers is not accurately known but is greater than usually supposed.

The carrier state not only follows recognized cases of typhoid fever but may result from those which, because of the unusual mildness of the symptoms, have not been recognized as typhoid. In a small percentage of cases no history of the occurrence of typhoid fever is obtainable. In this way nurses attending typhoid fever have become carriers. Chronic carriers may continue to discharge the bacilli for many years.

The elimination of typhoid bacilli from the intestinal and urinary tract is intermittent, rather than constant. The bacilli enter the intestine usually from the gall bladder and gall ducts, the seat of typhoidal inflammation. When a typhoidal cystitis exists, the organisms appear in the urine. A rarer condition resulting in the discharge of typhoid bacilli is post-typhoidal suppuration of bones, commonly at the junction of cartilaginous and osseous tissues and most often about the ribs, leading to the formation of discharging sinuses which may persist for long periods.

The treatment of typhoid carriers is perplexing and often unsatisfactory, and no treatment applicable to all cases has been discovered. Infection of the urinary bladder can frequently be suppressed by the administration of hexamethylamin. Discharging sinuses may be cured by appropriate surgical treatment. When the gall bladder alone is infected, surgical drainage or

extirpation removes the source of intestinal contamination. But when the infection exists in the biliary ducts within the liver, the condition can not be reached by surgical methods, and no reliable therapeutic measures for its suppression are known at the present time.

Every effort

Specimens of excreta to be forwarded to the State Laboratory for examination should be placed in the special containers provided for this purpose. Use the sterile swab enclosed in the tube for collecting the specimen, placing enough material upon the swab to avoid drying in transit. should be made to reduce delay in transmitting specimens to the laboratory to a minimum. Typhoid bacilli present in intestinal discharges diminish in number rapidly, a delay of 24 hours meaning, on the average, a loss of ten per cent in the number of organisms present.

Many important outbreaks of typhoid fever have been traced to carriers: engaged in handling milk or other foods consumed by others. In two wellknown instances domestics employed in one family after another have been responsible for the occurrence of cases in practically every family in which they have been employed.

A person of intelligence who is a carrier of typhoid bacilli, but who is willing to observe strictly certain essential precautions, may live and mingle with others and still need not be a source of danger to those about him. In formulating rules and regulations to be observed by carriers, the State Department of Health endeavors to restrict the activities of such persons to the smallest degree consistent with the protection of public health. By observing the following rules strictly, the carrier will not only avoid becoming a source of danger to those about him, but will be rendering: a public service.

Rules and regulations for control of typhoid carriers

1 A typhoid carrier is a person who harbors typhoid bacilli and emits them, regularly or intermittently. This condition may or may not follow a recognized attack of typhoid fever. A person continuing to discharge typhoid bacilli following an attack of typhoid fever, shall be regarded as a case, rather than a carrier, for a period of at least twelve weeks following subsidence of clinical symptoms. After that period, the IIealth Officer may, in his discretion, declare such person to be a carrier.

2 The Health Officer, upon the discovery of a typhoid carrier, shall immediately report the fact to the State Department of Health, giving the full name, age, occupation, and address of such carrier (together with any other information relative to possible or probable infection of others), and shall also communicate the fact to the carrier himself or his guardian, imparting to him detailed information regarding the precautions to be observed in disposing of his discharges, in preventing contamination of his hands, and thus protecting others from infection. Instruction given by the Health Officer should include a copy of these rules and regulations and directions to wash the hands thoroughly with soap and water immediately after using the toilet and to use individual towels and drinking and eating utensils, which should be thoroughly cleansed, preferably by boiling, before being used by others.

3 When an outside toilet is used regularly by a typhoid carrier, it shall be equipped with a watertight container so screened as to exclude flies, and the removal of the contents for disposal should be in accordance with instructions given by the Health Officer.

4 No typhoid carrier may engage in any occupation involving the handling of milk or other food product to be consumed by others. Should a typhoid carrier be discovered upon a dairy farm, the Health Officer may prohibit the sale of milk, cream, or butter, except under conditions stated in regulation 37, Chapter II, of the Sanitary Code.

5 No typhoid carrier shall permanently leave the community in which he resides without notification to the Health Officer, who is to be informed of his destination, including his new address. The Health Officer should immediately notify the State Department of Health of the change of address.

6 The local Health Officer shall visit each typhoid carrier within his jurisdiction at least once monthly in order to determine whether instructions are being complied with; and once in each quarter shall render a report regarding each such carrier to the State Department of Health upon a form prescribed for the purpose.

7 The Health Officer shall cause samples of the discharges from each carrier to be examined bacteriologically at intervals at a laboratory approved by the State Department of Health, and a carrier may be regarded as recovered and be discharged from observation when four successive samples, taken not less than seven days apart, shall have been found not to contain typhoid bacilli; except that no negative report shall be considered if the specimen has been delayed in transit, and in no instance if more than two days have elapsed between the collection of the specimen and its examination.

DIPHTHERIA CARRIERS

The persistence of diphtheria bacilli for a time in the throats and noses of persons recovering from diphtheria is not unusual, and does not denote a carrier state unless the organisms persist for several weeks. Carriers are not infrequently discovered who have apparently become such through contact with cases or with other carriers ("contact" carriers), although a searching inquiry may reveal the fact that they have actually suffered from mild attacks of the disease. Abnormal conditions in the mucous membranes of the nose and throat appear to be largely responsible for persistence of diphtheria bacilli. Persistent carriers usually are immune to infection and give negative Schick tests.

According to laboratory records approximately 95 per cent of cultures from recovered cases and contact carriers tested for virulence up to three months from date of onset have shown virulence. In view of this fact, and since the virulence test is one consuming several days, requests for such tests should not ordinarily be made within this period.

In making cultures from large numbers of individuals, as in schools or institutions in which there have been no cases of diphtheria, organisms will be found in about one or two per cent which closely resemble diphtheria bacilli, but which do not cause diphtheria or produce toxin. They can be distinguished from true diphtheria bacilli only by means of virulence tests